Driving with hemianopia, I: Detection performance in a driving simulator

Knowing me, knowing you-A study on top-down requirements for compensatory scanning in drivers with homonymous visual field loss

OBJECTIVE

It is currently still unknown why some drivers with visual field loss can compensate well for their visual impairment while others adopt ineffective strategies. This paper contributes to the methodological investigation of the associated top-down mechanisms and aims at validating a theoretical model on the requirements for successful compensation among drivers with homonymous visual field loss.

METHODS

A driving simulator study was conducted with eight participants with homonymous visual field loss and eight participants with normal vision. Participants drove through an urban surrounding and experienced a baseline scenario and scenarios with visual precursors indicating increased likelihoods of crossing hazards. Novel measures for the assessment of the mental model of their visual abilities, the mental model of the driving scene and the perceived attention demand were developed and used to investigate the top-down mechanisms behind attention allocation and hazard avoidance.

RESULTS

Participants with an overestimation of their visual field size tended to prioritize their seeing side over their blind side both in subjective and objective measures. The mental model of the driving scene showed close relations to the subjective and actual attention allocation. While participants with homonymous visual field loss were less anticipatory in their usage of the visual precursors and showed poorer performances compared to participants with normal vision, the results indicate a stronger reliance on top-down mechanism for drivers with visual impairments. A subjective focus on the seeing side or on near peripheries more frequently led to bad performances in terms of collisions with crossing cyclists.

CONCLUSION

The study yielded promising indicators for the potential of novel measures to elucidate top-down mechanisms in drivers with homonymous visual field loss. Furthermore, the results largely support the model of requirements for successful compensatory scanning. The findings highlight the importance of individualized interventions and driver assistance systems tailored to address these mechanisms.

Gaze Scanning at Street Crossings by Pedestrians With Homonymous Hemianopia With and Without Hemispatial Neglect

Purpose

To investigate compensatory gaze-scanning behaviors during street crossings by pedestrians with homonymous hemianopia (HH) and hemispatial neglect (HSN).

Methods

Pedestrians with right homonymous hemianopia (RHH) and left homonymous hemianopia without (LHH) and with left spatial-neglect (LHSN) walked on city streets wearing a gaze-tracking system that also captured scene videos. Street-crossing instances were manually annotated, and horizontal gaze scan of magnitude ≥20° and scanning rates were compared within-subject, between the side of the hemifield loss (BlindSide) and the other side (SeeingSide). Proportion of instances with scans to both the left and the right side at nonsignalized crossings (indicative of safe scanning behavior) were compared among the three subject groups.

Results

Data from 19 participants (6 LHH, 7 RHH, and 6 with mild [4] or moderate [2] LHSN), consisting of 521 street-crossing instances of a total duration of 201 minutes and 5375 gaze scans, were analyzed. The overall gaze magnitude (mean [95% confidence interval (CI)]) was significantly larger toward the BlindSide (40.4° [39.1°-41.9°]) than the SeeingSide (36° [34.8°-37.3°]; P < 0.001). The scanning rate (mean [95% CI] scans/min) toward the BlindSide (14 [12.5-15.6]) was significantly higher than the SeeingSide (11.5 [10.3°-12.9°]; P < 0.001). The scanning rate in the LHSN group (10.7 [8.9-12.8]) was significantly lower than the LHH group (14 [11.6-17.0]; P = 0.045). The proportion of nonsignalized crossings with scans to both sides was significantly lower in LHSN (58%; P = 0.039) and RHH (51%; P = 0.003) than LHH (75%) participants.

Conclusions

All groups demonstrated compensatory scanning, making more gaze scans with larger magnitudes to the blind side. Mild to moderate LHSN adversely impacted the scanning rate.

The Effects of Visual Field Loss from Stroke on Performance in a Driving Simulator

SIGNIFICANCE

Visual field loss (VFL) is a common consequence of stroke and often precludes driving. However, legal visual requirements for drivers' licenses are largely without scientific basis.

PURPOSE

To examine the effects of different types of homonymous VFL after stroke on simulated driving.

METHODS

Data on performance and safety from a traffic simulator test for 153 participants with withdrawn drivers' licenses due to visual field loss from stroke was retrospectively compared with data from 83 healthy individuals without visual deficits in a cross-sectional study. The 93 individuals in the stroke group that regained their driving licenses after a successful simulator test were then followed in a national accident database.

RESULTS

Sixty-five per cent of the stroke participants passed the simulator test (95% confidence interval 57-72%). Younger patients were more successful than older. However, neither classification by type of homonymous visual field loss, nor by side of visual field loss was predictive of driver safety. Participants with hemianopia had their lateral lane position dislocated to the non-affected side of the visual field. None of the participants with a regained license were involved in motor vehicle accidents three to six years after the test.

CONCLUSIONS

In this large cohort, driver safety could not be predicted from the type of homonymous visual field loss. Even individuals with severe visual field loss might be safe drivers. Therefore, it seems reasonable to provide an opportunity for individualized assessments of practical fitness to drive in circumstances of licensing issues. This study demonstrates the potential of using a standardized driving simulator test for such assessments of fitness to drive.

Driving With Hemianopia X: Effects of Cross Traffic on Gaze Behaviors and Pedestrian Responses at Intersections

Purpose

We conducted a driving simulator study to investigate the effects of monitoring intersection cross traffic on gaze behaviors and responses to pedestrians by drivers with hemianopic field loss (HFL).

Methods

Sixteen HFL and sixteen normal vision (NV) participants completed two drives in an urban environment. At 30 intersections, a pedestrian ran across the road when the participant entered the intersection, requiring a braking response to avoid a collision. Intersections with these pedestrian events had either (1) no cross traffic, (2) one approaching car from the side opposite the pedestrian location, or (3) two approaching cars, one from each side at the same time.

Results

Overall, HFL drivers made more (p < 0.001) and larger (p = 0.016) blind- than seeing-side scans and looked at the majority (>80%) of cross-traffic on both the blind and seeing sides. They made more numerous and larger gaze scans (p < 0.001) when they fixated cars on both sides (compared to one or no cars) and had lower rates of unsafe responses to blind- but not seeing-side pedestrians (interaction, p = 0.037). They were more likely to demonstrate compensatory blind-side fixation behaviors (faster time to fixate and longer fixation durations) when there was no car on the seeing side. Fixation behaviors and unsafe response rates were most similar to those of NV drivers when cars were fixated on both sides.

Conclusion

For HFL participants, making more scans, larger scans and safer responses to pedestrians crossing from the blind side were associated with looking at cross traffic from both directions. Thus, cross traffic might serve as a reminder to scan and provide a reference point to guide blind-side scanning of drivers with HFL. Proactively checking for cross-traffic cars from both sides could be an important safety practice for drivers with HFL.

Opportunities and Limitations of a Gaze-Contingent Display to Simulate Visual Field Loss in Driving Simulator Studies

Background

Research on task performance under visual field loss is often limited due to small and heterogenous samples. Simulations of visual impairments hold the potential to account for many of those challenges. Digitally altered pictures, glasses, and contact lenses with partial occlusions have been used in the past. One of the most promising methods is the use of a gaze-contingent display that occludes parts of the visual field according to the current gaze position. In this study, the gaze-contingent paradigm was implemented in a static driving simulator to simulate visual field loss and to evaluate parallels in the resulting driving and gaze behavior in comparison to patients.

Methods

The sample comprised 15 participants without visual impairment. All the subjects performed three drives: with full vision, simulated left-sided homonymous hemianopia, and simulated right-sided homonymous hemianopia, respectively. During each drive, the participants drove through an urban environment where they had to maneuver through intersections by crossing straight ahead, turning left, and turning right.

Results

The subjects reported reduced safety and increased workload levels during simulated visual field loss, which was reflected in reduced lane position stability and greater absence of large gaze movements. Initial compensatory strategies could be found concerning a dislocated gaze position and a distorted fixation ratio toward the blind side, which was more pronounced for right-sided visual field loss. During left-sided visual field loss, the participants showed a smaller horizontal range of gaze positions, longer fixation durations, and smaller saccadic amplitudes compared to right-sided homonymous hemianopia and, more distinctively, compared to normal vision.

Conclusion

The results largely mirror reports from driving and visual search tasks under simulated and pathological homonymous hemianopia concerning driving and scanning challenges, initially adopted compensatory strategies, and driving safety. This supports the notion that gaze-contingent displays can be a useful addendum to driving simulator research with visual impairments if the results are interpreted considering methodological limitations and inherent differences to the pathological impairment.

Change blindness in simulated driving in individuals with homonymous visual field loss

Individuals with homonymous visual field loss (HVFL) fail to perceive visual information that falls within the blind portions of their visual field. This places additional burden on memory to represent information in their blind visual field, which may make visual changes in the scene more difficult to detect. Failing to detect changes could have serious implications in the context of driving. A change blindness driving simulator experiment was conducted with individuals with HVFL (n = 17) and in those with normal vision (NV; n = 16) where changes (pedestrians appearing) were triggered based on the driver’s gaze location. Gaze was used to ensure that the location of the change was visible before and after the change occurred. There were wide individual differences in both vision groups, ranging from no change blindness to more than 33% of events. Those with HVFL had more change blindness than those with NV (16.7% vs. 6.3%, p < 0.001) and more change blindness to pedestrians appearing in their blind than seeing hemifield (34.6% vs. 10.4%, p < 0.001). Further, there was more change blindness for events appearing in the seeing hemifield for those with HVFL than normal vision (p = 0.023). These results suggest that individuals with HVFL may be more susceptible to failures of awareness, such as change blindness, than individuals with normal vision. Increased risk for failures of awareness may result in motor vehicle crashes where the driver fails to notice the other road user (looked-but-failed-to-see incidents).

Influence of Vision on Drivers: A Pilot Study

Background: Driving is the main mode of transportation in many countries, and visual safety depends largely on good visual health. The objective of this study is to analyze the visual health of Spanish drivers; as well as analyze the difference between professional and non-professional drivers. Methods: A visual screening was carried out in Spanish drivers from all over Spain, in which the following tests were performed: monocular visual acuity in distance and near vision, visual field, stereopsis, contrast sensitivity, intraocular pressure and balance test binocular. Subsequently, a questionnaire was carried out on the patient’s driving data and ocular antecedents. Results: 74.5% of the drivers used glasses to drive, of which 61.5% used progressive glasses. However, 39.4% reported having difficulties seeing well. The mean visual acuity in the distance and near was 0.93 ± 0.13 and 0.94 ± 0.13, respectively. Significant differences have been found in accident risk based on visual acuity (p < 0.001). But no significant differences have been found in terms of visual field, stereopsis, contrast sensitivity, binocular balance and intraocular pressure (p > 0.05). Conclusion: Vision appears to play a key role in driving and a good visual assessment is recommended for early detection of visual problems that may affect road safety. A study with a larger sample size would be necessary to confirm the results of this pilot study.

Driving with hemianopia VIII: Effects of a vibro-tactile assistance system on safety and gaze behavior in pedestrian crossing situations

People with homonymous visual field defects (HVFDs), the loss of vision in the same half of the visual field in both eyes, are permitted to drive in some jurisdictions. However, the HVFD may cause difficulties in detecting hazards approaching on the side of the field loss (the blind side). An advanced driver assistance system (ADAS) could assist with hazard detection, but little research has been conducted to evaluate the potential benefits of an ADAS for visually impaired drivers. We developed a prototype vibro-tactile assistance system for drivers with HVFDs and conducted a proof-of-concept driving simulation study to evaluate the system. Given that pedestrian accidents are the second most frequent cause of death in road traffic and most of those accidents occur in urban scenarios, we evaluated the potential of the assistance system to improve responses to pedestrian hazards in a city environment. Sixteen participants, of which eight had HVFDs and eight had normal vision, took part. Our analyses evaluated the effects of the driver assistance system, crossing direction and pedestrian behavior on the safety of pedestrian events and the participant's gaze behavior at each of the 256 crossing situations. Generalized linear mixed effects models were used to assess binomial outcome variables. Despite the limited sample size, the results suggest that the vibro-tactile directional warnings were effective in directing the drivers' gaze so that they were looking in the necessary direction before a potential hazard occurred. More time was spent fixating pedestrians on the blind side when the ADAS was engaged and as a result, the safety of street crossings from the blind side improved. The effect of the ADAS was greater on responses to pedestrians from the blind than the seeing side. With an activated ADAS, crossings from the participants' blind sides were as safe as from their seeing sides, and as safe as the crossings when normally-sighted participants were driving. The results suggest that the vibro-tactile ADAS is a promising approach to improve the safety of drivers with HVFD and surrounding traffic.

Motor Vehicle Accident Due to Homonymous Hemianopia: An Unusual Presentation of Vertebrobasilar Stroke

Acute ischemic stroke may present with various symptoms, including weakness, altered speech, and sensory and visual impairment. We present a case of a 57-year-old man who was brought to the emergency department after he sustained three minor motor vehicle accidents on the same day. After clinical assessment and detailed workup, we concluded that our patient had an acute ischemic infarct involving the left posterior cerebral artery territories causing right homonymous hemianopia resulting in motor vehicle accidents.

Inpatient Virtual Vision Clinic Improves Access to Vision Rehabilitation Before and During the COVID-19 Pandemic

OBJECTIVE

To describe and evaluate a secure video call system combined with a suite of iPad vision testing apps to improve access to vision rehabilitation assessment for inpatients.

DESIGN

Retrospective.

SETTING

Two acute care inpatient rehabilitation hospitals and 1 long-term acute care (LTAC) hospital.

PARTICIPANTS

Records of inpatients seen by the vision service.

INTERVENTIONS

Records from a 1-year telemedicine pilot performed at acute rehabilitation (AR) hospital 1 and then expanded to AR hospital 2 and LTAC hospital during coronavirus disease 2019 (COVID-19) were reviewed. In the virtual visits, an occupational therapist measured the patients' vision with the iPad applications and forwarded results to the off-site Doctor of Optometry (OD) for review prior to a video visit. The OD provided diagnosis and education, press-on prism application supervision, strategies and modifications, and follow-up recommendations. Providers completed the telehealth usability questionnaire (10-point scale).

MAIN OUTCOME MEASURES

Vision examinations per month at AR hospital 1 before and with telemedicine.

RESULTS

With telemedicine at AR hospital 1, mean visits per month significantly increased from 10.7±5 to 14.9±5 (P=.002). Prism was trialed in 40% of cases of which 83% were successful, similar to previously reported in-person success rates. COVID-19 caused only a marginal decrease in visits per month (P=.08) at AR1, whereas the site without an established program (AR hospital 2) had a 3-4 week gap in care while the program was initiated. Cases at the LTAC hospital tended to be more complex and difficult to manage virtually. The telehealth usability questionnaire median category scores were 7 for Ease of Use, 8 for Interface Quality, 6 for Reliability, and 9 for Satisfaction and Future Use.

CONCLUSIONS

The virtual vision clinic process improved inpatient access to eye and visual neurorehabilitation assessment before and during the COVID-19 quarantine and was well accepted by providers and patients.

SCOTOMAS IN THE VISUAL FIELD AS THE FIRST SIGN OF INTRACRANIAL EXPANSION. CASE REPORT

The most common cause of visual field loss in ophthalmology is glaucoma. Other causes of visual field damage include local damage to the eye itself in intrabulbar or retrobulbar neuritis or injuries. However, they can also be caused by general diseases, e.g. in endocrine orbitopathy, toxic and nutritional neuropathy, or in diseases that are localized intracranially. Each of these findings in itself suggests the nature of the lesion, its intracranial location, lateral occurrence, as well as in which part of the visual pathway the lesion is located. The use of perimeter has therefore become the primary examination method, which is available, is not demanding and will quickly allow a diagnosis to be made. When found on a perimetric examination, it is necessary to indicate targeted imaging examinations, such as computed tomography or magnetic resonance imaging. The article describes a patient who was primarily examined at the Department of Ophthalmology, Faculty of Medicine, Comenius University and the University hospital of Bratislava. The patient reported visual field outages, and after subsequent computed tomography, she was interdisciplinary managed and surgery was done on at the Neurosurgical Department. After the operation, there was a significant improvement without a pathological finding on the perimeter.

Driving With Hemianopia VII: Predicting Hazard Detection With Gaze and Head Scan Magnitude

Purpose

One rehabilitation strategy taught to individuals with hemianopic field loss (HFL) is to make a large blind side scan to quickly identify hazards. However, it is not clear what the minimum threshold is for how large the scan should be. Using driving simulation, we evaluated thresholds (criteria) for gaze and head scan magnitudes that best predict detection safety.

Methods

Seventeen participants with complete HFL and 15 with normal vision (NV) drove through 4 routes in a virtual city while their eyes and head were tracked. Participants pressed the horn as soon as they detected a motorcycle (10 per drive) that appeared 54 degrees eccentricity on cross-streets and approached toward the driver.

Results

Those with HFL detected fewer motorcycles than those with NV and had worse detection on the blind side than the seeing side. On the blind side, both safe detections and early detections (detections before the hazard entered the intersection) could be predicted with both gaze (safe 18.5 degrees and early 33.8 degrees) and head (safe 19.3 degrees and early 27 degrees) scans. However, on the seeing side, only early detections could be classified with gaze (25.3 degrees) and head (9.0 degrees).

Conclusions

Both head and gaze scan magnitude were significant predictors of detection on the blind side, but less predictive on the seeing side, which was likely driven by the ability to use peripheral vision. Interestingly, head scans were as predictive as gaze scans.

Translational Relevance

The minimum scan magnitude could be a useful criterion for scanning training or for developing assistive technologies to improve scanning.

2017 Charles F. Prentice Award Lecture: Peripheral Prisms for Visual Field Expansion: A Translational Journey

On the occasion of being awarded the Prentice Medal, I was asked to summarize my translational journey. Here I describe the process of becoming a low-vision rehabilitation clinician and researcher, frustrated by the unavailability of effective treatments for some conditions. This led to decades of working to understand patients' needs and the complexities and subtleties of their visual systems and conditions. It was followed by many iterations of developing vision aids and the techniques needed to objectively evaluate their benefit. I specifically address one path: the invention and development of peripheral prisms to expand the visual fields of patients with homonymous hemianopia, leading to our latest multiperiscopic prism (mirror-based design) with its clear 45° field-of-view image shift.

Effects of driver compensatory behaviour on risks of critical pedestrian collisions under simulated visual field defects

Compensatory behaviour is regarded as a helpful strategy to mediate drivers’ deteriorated hazard perception ability due to visual field defects. However, helpfulness of compensatory behaviour for drivers with advanced visual field defects has largely unexplored. This study aims to clarify the effectiveness and limitation of compensatory head movements in critical situations where included pedestrians stepping off a sidewalk under the simulation of advanced visual defects. 18 healthy-sighted drivers participated the data collection that was conducted in a driving simulator under three driving conditions: (1) without visual impairment, (2) with visual impairment and not performing active compensation, and (3) with visual impairment but performing active compensation. The result showed that active compensation led quick accelerator and brake response times, reducing the risk and number of pedestrian collisions. The active compensation led a decrease in the number of non-responses to hazardous pedestrians compared to while driving not performing compensation. However, the compensation could not reduce the number of pedestrian collisions to those of healthy-sighted drivers. Compensatory viewing behaviour contributed to improved driving performance as well as has limits to lead driving performance like healthy-sighted drivers. Developing driver assistance systems and practical compensatory strategies concerning the degrees of impairment and traffic conditions may provide opportunities to improve driving safety deteriorated hazard perception for visually impaired drivers.

Peripheral Prisms Improve Obstacle Detection during Simulated Walking for Patients with Left Hemispatial Neglect and Hemianopia

SIGNIFICANCE

The first report on the use of peripheral prisms (p-prisms) for patients with left neglect and homonymous visual field defects (HVFDs).

PURPOSE

The purpose of this study was to investigate if patients with left hemispatial neglect and HVFDs benefit from p-prisms to expand the visual field and improve obstacle detection.

METHODS

Patients (24 with HVFDs, 10 of whom had left neglect) viewed an animated, virtual, shopping mall corridor and reported if they would have collided with a human obstacle that appeared at various offsets up to 13.5° from their simulated walking path. There were 40 obstacle presentations on each side, with and without p-prisms. No training with p-prisms was provided, and gaze was fixed at the center of expansion.

RESULTS

Detection on the side of the HVFD improved significantly with p-prisms in both groups, from 26 to 92% in the left-neglect group and 43 to 98% in the non-neglect group (both P < .001). There was a tendency for greater improvement in the neglect patients with p-prisms. For collision judgments, both groups exhibited a large increase in perceived collisions on the side of the HVFD with the prisms (P < .001), with no difference between the groups (P = .93). Increased perceived collisions represent a wider perceived safety margin on the side of the HVFD.

CONCLUSIONS

Within the controlled conditions of this simulated, collision judgment task, patients with left neglect responded well to initial application of p-prisms exhibiting improved detection and wider safety margins on the side of the HVFD that did not differ from non-neglect patients. Further study of p-prisms for neglect patients in free-gaze conditions after extended wear and in real-world mobility tasks is clearly warranted.

The Impact of Visual Field Loss on Driving Skills: A Systematic Narrative Review

Purpose

To review the evidence on the impact of visual field loss on skills required for driving.

Methods

A literature search was undertaken using a systematic approach. Papers within scope were identified by two independent reviewers, and papers were grouped into similar themes for discussion.

Key findings

Evidence suggests that both binocular and monocular visual field defects have a negative impact on driving skills. Both central and peripheral cause difficulties, but the degree of impact is dependent on the defect severity and compensation ability. Many factors that affect compensation to visual field loss and the effects of visual field loss on driving skills are discussed, including cognitive status, age and duration of visual field loss. In summary, in central visual field loss compensation, strategies include reduction of overall driving speed; whereas, in peripheral field loss, increased scanning is reported to aid adaptation.

Conclusions

For driving, there is evidence that complete and/or binocular visual field loss poses more of a difficulty than partial and/or monocular loss, and central defects cause more problems than peripheral defects. A lack of evidence exists concerning the impact of superior versus inferior defects. The level of peripheral vision loss that is incompatible with safe driving remains unknown, as compensation abilities vary widely between individuals. This review highlights a lack of evidence in relation to the impact of visual field loss on driving skills. Further research is required to strengthen the evidence to allow clinicians to better support people with visual field loss with driving advice.

Field Expansion for Acquired Monocular Vision Using a Multiplexing Prism

SIGNIFICANCE

Acquired monocular vision (AMV) is a common visual field loss. Patients report mobility difficulties in walking due to collisions with objects or other pedestrians on the blind side.

PURPOSE

The visual field of people with AMV extends more than 90° temporally on the side of the seeing eye but is restricted to approximately 55° nasally. We developed a novel field expansion device using a multiplexing prism (MxP) that superimposes the see-through and shifted views for true field expansion without apical scotoma. We present various designs of the device that enable customized fitting and improved cosmetics.

METHODS

A partial MxP segment is attached (base-in) near the nose bridge. To avoid total internal reflection due to the high angle of incidence at nasal field end (55°), we fit the MxP with serrations facing the eye and tilt the prism base toward the nose. We calculated the width of the MxP (the apex location) needed to prevent apical scotoma and monocular diplopia. We also consider the effect of spectacle prescriptions on these settings. The results are verified perimetrically.

RESULTS

We documented the effectivity of various prototype glasses designs with perimetric measurements. With the prototypes, all patients with AMV had field-of-view expansions up to 90° nasally without any loss of seeing field.

CONCLUSIONS

The novel and properly mounted MxP in glasses has the potential for meaningful field-of-view expansion up to the size of normal binocular vision in cosmetically acceptable form.

Measuring the Difficulty Watching Video With Hemianopia and an Initial Test of a Rehabilitation Approach

PURPOSE

If you cannot follow the story when watching a video, then the viewing experience is degraded. We measured the difficulty of following the story, defined as the ability to acquire visual information, which is experienced by people with homonymous hemianopia (HH). Further, we proposed and tested a novel rehabilitation aid.

METHODS

Participants watched 30-second directed video clips. Following each video clip, subjects described the visual content of the clip. An objective score of information acquisition (IA) was derived by comparing each new response to a control database of descriptions of the same clip using natural language processing. Study 1 compared 60 participants with normal vision (NV) to 24 participants with HH to test the hypothesis that participants with HH would score lower than NV participants, consistent with reports from people with HH that describe difficulties in video watching. In the second study, 21 participants with HH viewed clips with or without a superimposed dynamic cue that we called a content guide. We hypothesized that IA scores would increase using this content guide.

RESULTS

The HH group had a significantly lower IA score, with an average of 2.8, compared with 4.3 shared words of the NV group (mixed-effects regression, P < 0.001). Presence of the content guide significantly increased the IA score by 0.5 shared words (P = 0.03).

CONCLUSIONS

Participants with HH had more difficulty acquiring information from a video, which was objectively demonstrated (reduced IA score). The content guide improved information acquisition, but not to the level of people with NV.

TRANSLATIONAL RELEVANCE

The value as a possible rehabilitation aid of the content guide warrants further study that involves an extended period of content-guide use and a randomized controlled trial.

Does Central Vision Loss Impair Visual Search Performance of Adults More than Children?

SIGNIFICANCE

In general, young adults with normal vision show the best visual search performance when compared with children and older adults. Through our study, we show that this trend is not observed in individuals with vision impairment. An interaction effect of vision impairment with visual development and aging is observed.

PURPOSE

Performance in many visual tasks typically shows improvement with age until young adulthood and then declines with aging. Using a visual search task, this study investigated whether a similar age effect on performance is present in people with central vision loss.

METHODS

A total of 98 participants, 37 with normal sight (NS) and 61 with visual impairment (VI) searched for targets in 150 real-world digital images. Search performance was quantified by an integrated measure combining speed and accuracy. Participant ages ranged from 5 to 74 years, visual acuity from -0.14 (20/14.5) to 1.16 logMAR (20/290), and log contrast sensitivity (CS) from 0.48 to 2.0. Data analysis was performed with participants divided into three age groups: children (aged <14 years, n = 25), young adults (aged 14 to 45 years, n = 47), and older adults (aged >45 years, n = 26).

RESULTS

Regression (r = 0.7) revealed CS (P < .001) and age (P = .003) were significant predictors of search performance. Performance of VI participants was normalized to the age-matched average performance of the NS group. In the VI group, it was found that children's normalized performance (52%) was better than both young (39%, P = .05) and older (40%, P = .048) adults.

CONCLUSIONS

Unlike NS participants, young adults in the VI group may not have search ability superior to children with VI, despite having the same level of visual functions (quantified by visual acuity and CS). This could be because of vision impairment limiting the developmental acquisition of the age dividend for peak performance. Older adults in the VI group had the worst performance, indicating an interaction of aging.

People with Hemianopia Report Difficulty with TV, Computer, Cinema Use, and Photography

SIGNIFICANCE

Our survey found that participants with hemianopia report more difficulties watching video in various formats, including television (TV), on computers, and in a movie theater, compared with participants with normal vision (NV). These reported difficulties were not as marked as those reported by people with central vision loss.

PURPOSE

The aim of this study was to survey the viewing experience (e.g., frequency, difficulty) of viewing video on TV, computers and portable visual display devices, and at the cinema of people with hemianopia and NV. This information may guide vision rehabilitation.

METHODS

We administered a cross-sectional survey to investigate the viewing habits of people with hemianopia (n = 91) or NV (n = 192). The survey, consisting of 22 items, was administered either in person or in a telephone interview. Descriptive statistics are reported.

RESULTS

There were five major differences between the hemianopia and NV groups. Many participants with hemianopia reported (1) at least "some" difficulty watching TV (39/82); (2) at least "some" difficulty watching video on a computer (16/62); (3) never attending the cinema (30/87); (4) at least some difficulty watching movies in the cinema (20/56), among those who did attend the cinema; and (5) never taking photographs (24/80). Some people with hemianopia reported methods that they used to help them watch video, including video playback and head turn.

CONCLUSIONS

Although people with hemianopia report more difficulty with viewing video on TV and at the cinema, we are not aware of any rehabilitation methods specifically designed to assist people with hemianopia to watch video. The results of this survey may guide future vision rehabilitation.

Driving With Hemianopia VI: Peripheral Prisms and Perceptual-Motor Training Improve Detection in a Driving Simulator

Purpose

Drivers with homonymous hemianopia (HH) were previously found to have impaired detection of blind-side hazards, yet in many jurisdictions they may obtain a license. We evaluated whether oblique 57Δ peripheral prisms (p-prisms) and perceptual-motor training improved blind-side detection rates.

Methods

Patients with HH (n = 11) wore p-prisms for 2 weeks and then received perceptual-motor training (six visits) detecting and touching stimuli in the prism-expanded vision. In a driving simulator, patients drove and pressed the horn upon detection of pedestrians who ran toward the roadway (26 from each side): (1) without p-prisms at baseline; (2) with p-prisms after 2 weeks acclimation but before training; (3) with p-prisms after training; and (4) 3 months later.

Results

P-prisms improved blind-side detection from 42% to 56%, which further improved after training to 72% (all P < 0.001). Blind-side timely responses (adequate time to have stopped) improved from 31% without to 44% with p-prisms (P < 0.001) and further improved with training to 55% (P = 0.02). At the 3-month follow-up, improvements from training were maintained for detection (65%; P = 0.02) but not timely responses (P = 0.725). There was wide between-subject variability in baseline detection performance and response to p-prisms. There were no negative effects of p-prisms on vehicle control or seeing-side performance.

Conclusions

P-prisms improved detection with no negative effects, and training may provide additional benefit.

Translational Relevance

In jurisdictions where people with HH are legally driving, these data aid in clinical decision making by providing evidence that p-prisms improve performance without negative effects.

Pupil response as an indicator of hazard perception during simulator driving

We investigate the pupil response to hazard perception during driving simulation. Complementary to gaze movement and physiological stress indicators, pupil size changes can provide valuable information on traffic hazard perception with a relatively low temporal delay. We tackle the challenge of identifying those pupil dilation events associated with hazardous events from a noisy signal by a combination of wavelet transformation and machine learning. Therefore, we use features of the wavelet components as training data of a support vector machine. We further demonstrate how to utilize the method for the analysis of actual hazard perception and how it may differ from the behavioral driving response.

Driving with Hemianopia V: Do Individuals with Hemianopia Spontaneously Adapt Their Gaze Scanning to Differing Hazard Detection Demands?

Purpose

We investigated whether people with homonymous hemianopia (HH) were able to spontaneously (without training or instructions) adapt their blind-side scan magnitudes in response to differing scanning requirements for detection of pedestrians in a driving simulator when differing cues about pedestrian eccentricities and movement behaviors were available in the seeing hemifield.

Methods

Twelve HH participants completed two sessions in a driving simulator pressing the horn when they detected a pedestrian. Stationary pedestrians outside the driving lane were presented in one session and approaching pedestrians on a collision course in the other. Gaze data were analyzed for pedestrians initially appearing at approximately 14° in the blind hemifield. No instructions were given regarding scanning.

Results

After appearing, the stationary pedestrians' eccentricity increased rapidly to a median of 31° after 2.5 seconds, requiring increasingly larger blind-side gaze scans for detection, while the approaching pedestrians' eccentricity remained constant at approximately 14°, requiring a more moderate scan (∼14°) for detection. Although median scan magnitudes did not differ between the two conditions (approaching: 14° [IQR 9°–15°]; stationary: 13° [IQR 9°–20°]; P = 0.43), three participants showed evidence of adapting (increasing) their blind-side scan magnitudes in the stationary condition.

Conclusions

Three participants (25%) appeared to be able to apply voluntary cognitive control to modify their blind-side gaze scanning in response to the differing scanning requirements of the two conditions without explicit training.

Translational Relevance

Our results suggest that only a minority of people with hemianopia are likely to be able to spontaneously adapt their blind-side scanning in response to rapidly changing and unpredictable situations in on-road driving.

Restoration of Vision After Brain Injury Using Magnet Glasses

Visual impairments are common after traumatic brain injury (TBI) and negatively affect quality of life. We describe a 39-year-old woman with a severe TBI who was evaluated by the inpatient optometry and vision rehabilitation service with findings of complete right homonymous hemianopia and right cranial nerve III palsy with 30-degree right exotropia (eye turn out) and complete right ptosis (eyelid will not open). The 30-degree exotropia advantageously generated 30 degrees of right visual field expansion when the right ptosis was treated with a magnetic levator prosthesis, which restores eyelid opening. Once opened, the patient used visual field expansion derived from a right exotropia to overcome functional impairments caused by right hemianopia. Field expansion improved the patient's wheelchair mobility and reaching tasks during inpatient therapy. This is the first report of visual field expansion by strabismus facilitated by correction of ptosis. Strabismus should be considered for its potential field expansion benefits when homonymous visual deficits are present, before considering patching. A multidisciplinary vision rehabilitation team is well suited to make this determination.

Driving with homonymous visual field loss: a review of the literature

Driving is an important rehabilitation goal for patients with homonymous field defects (HFDs); however, whether or not people with HFDs should be permitted to drive is not clear. Over the last 15 years, there has been a marked increase in the number of studies evaluating the effects of HFDs on driving performance. This review of the literature provides a much-needed summary for practitioners and researchers, addressing the following topics: regulations pertaining to driving with HFDs, self-reported driving difficulties, pass rates in on-road tests, the effects of HFDs on lane position and steering stability, the effects of HFDs on scanning and detection of potential hazards, screening for potential fitness to drive, evaluating practical fitness to drive and the efficacy of interventions to improve driving of persons with HFDs. Although there is clear evidence from on-road studies that some people with HFDs may be rated as safe to drive, others are reported to have significant deficits in skills important for safe driving, including taking a lane position too close to one side of the travel lane, unstable steering and inadequate viewing (scanning) behaviour. Driving simulator studies have provided strong evidence of a wide range in compensatory scanning abilities and detection performance, despite similar amounts of visual field loss. Conventional measurements of visual field extent (in which eye movements are not permitted) do not measure such compensatory abilities and are not predictive of on-road driving performance. Thus, there is a need to develop better tests to screen people with HFDs for visual fitness to drive. We are not yet at a point where we can predict which HFD patient is likely to be a safe driver. Therefore, it seems only fair to provide an opportunity for individualised assessments of practical fitness to drive either on the road and/or in a driving simulator.

Driving with central field loss III: vehicle control

BACKGROUND

Visual impairment associated with central field loss may make vehicle control more difficult due to the degraded view of the road. We evaluated how central field loss affects vehicle control in a driving simulator.

METHODS

Nineteen participants with binocular central field loss (acuity 6/9 to 6/60) and 15 controls with normal vision drove 10 scenarios, each about eight to 12 minutes. Speed, lane offset and steering wheel reversal rate were measured on straights, left and right curves, along city (approximately 50 km/h) and rural highway (approximately 100 km/h) routes. Following distance was measured on two city straight segments.

RESULTS

Subjects with central field loss had higher steering wheel reversal rates (0.55 versus 0.45 reversals per second, p = 0.015), suggesting that the steering task was more demanding for them, requiring more steering corrections; however, they did not differ in other performance measures. Nearly all maintained a safe following distance, although they were more likely than controls with normal vision to lose sight of the lead car in scenarios that required following a car.

CONCLUSIONS

Most measures of vehicle control did not significantly differ between participants with central field loss and those with normal vision; however, the higher steering wheel reversal rates suggest that, in compensating for their vision impairment, drivers with central field loss had to allocate extra steering effort to maintain their lane position, which in turn could reduce attentional resources for other driving tasks.

Motor Vehicle Collision Involvement among Persons with Hemianopia and Quadrantanopia

Persons with homonymous quadrantanopia and hemianopia experience driving restrictions, yet there is little scientific evidence to support driving prohibition among persons with these conditions. This retrospective cohort study compares motor vehicle collision (MVC) rates among 27 current licensed drivers with hemianopic and quadrantanopic field defects, who were ≥6 months from the brain injury date with that of 27 age-matched drivers with normal visual fields. Information regarding all police-reported MVCs that occurred over a period of nine years was obtained. MVC rates per year and per mile travelled were calculated and compared using conditional Poisson regression. Drivers with hemianopia or quadrantanopia had more MVCs per mile driven compared to drivers with normal visual fields; specifically their overall MVC rate was 2.45-times (95% confidence interval (CI) 0.89–3.95) higher and their at-fault MVC rate was 2.64-times (95% CI 1.03–6.80) higher. This study indicates that drivers with hemianopia or quadrantanopia have elevated MVC rates. This is consistent with previous research despite studies showing wide individual variability from excellent to poor driving skills. Future research should focus on the functional and driving performance characteristics associated with superior driving skills and/or those that may be amenable to improvement via behavioral and/or engineering interventions.

Ocular disease and driving

As the driving population ages, the number of drivers with visual impairment resulting from ocular disease will increase given the age-related prevalence of ocular disease. The increase in visual impairment in the driving population has a number of implications for driving outcomes. This review summarises current research regarding the impact of common ocular diseases on driving ability and safety, with particular focus on cataract, glaucoma, age-related macular degeneration, hemianopia and diabetic retinopathy. The evidence considered includes self-reported driving outcomes, driving performance (on-road and simulator-based) and various motor vehicle crash indices. Collectively, this review demonstrates that driving ability and safety are negatively affected by ocular disease; however, further research is needed in this area. Older drivers with ocular disease need to be aware of the negative consequences of their ocular condition and in the case where treatment options are available, encouraged to seek these earlier for optimum driving safety and quality of life benefits.

Relearning to See in Cortical Blindness

The incidence of cortically induced blindness is increasing as our population ages. The major cause of cortically induced blindness is stroke affecting the primary visual cortex. While the impact of this form of vision loss is devastating to quality of life, the development of principled, effective rehabilitation strategies for this condition lags far behind those used to treat motor stroke victims. Here we summarize recent developments in the still emerging field of visual restitution therapy, and compare the relative effectiveness of different approaches. We also draw insights into the properties of recovered vision, its limitations and likely neural substrates. We hope that these insights will guide future research and bring us closer to the goal of providing much-needed rehabilitation solutions for this patient population.

Screening and assessment tools for determining fitness to drive: a review of the literature for the pathways project

With a brief introduction, 10 tables summarize the findings from the literature describing screening and assessment tools used with older adults to identify risk or determine fitness to drive. With a focus on occupational therapy's duty to address driving as a valued activity, this paper offers information about tools used by occupational therapy practitioners across practice settings and specialists in driver rehabilitation. The tables are organized into groups of key research studies of assessment tools, screening batteries, tools used in combination (i.e., as a battery), driving simulation as an assessment tool, and screening/assessment for individuals with stroke, vision impairment, Parkinson's disease, dementia, and aging. Each table has a summary of important concepts to consider as occupational therapists choose the methods and tools to evaluate fitness to drive.

Asymmetry in the Collision Judgments of People With Homonymous Field Defects and Left Hemispatial Neglect

PURPOSE

Although the impact of homonymous visual field defects (HFDs) on mobility has been investigated previously, the emphasis has been on obstacle detection. Relatively little is known about HFD patients' ability to judge collisions once an obstacle is detected. We investigated this using a walking simulator.

METHODS

Patients with HFDs (n = 29) and subjects with normal vision (NV; n = 21) were seated in front of a large screen on which a visual simulation of walking was displayed. They made collision judgments for a human figure that appeared for 1 second at lateral offsets from the virtual walking path. A perceived-collision threshold was calculated for right and left sides.

RESULTS

Symmetrical collision thresholds (same on left and right sides) were measured for participants with NV (n = 21), and right (n = 9) and left (n = 7) HFD without hemispatial neglect. Participants with left neglect (n = 10) showed significant asymmetry with thresholds smaller (compared to the NV group and other HFD groups) on the blind (P < 0.001) and larger on the seeing (P = 0.05) sides. Despite the asymmetry, the overall width of the zone of perceived collision risk was not different, suggesting a relatively uniform rightward deviation in judgments of the left neglect group.

CONCLUSIONS

Left neglect was associated with rightward asymmetry in collision judgments, which may cause collisions on the left side even when an obstacle is detected. These behaviors may represent the spatial misperceptions in body midline described previously in patients with left neglect.

A roadmap for interpreting the literature on vision and driving

Over the past several decades there has been a sharp increase in the number of studies focused on the relationship between vision and driving. The intensified attention to this topic has most likely been stimulated by the lack of an evidence basis for determining vision standards for driving licensure and a poor understanding about how vision impairment impacts driver safety and performance. Clinicians depend on the literature on vision and driving to advise visually impaired patients appropriately about driving fitness. Policy makers also depend on the scientific literature in order to develop guidelines that are evidence-based and are thus fair to persons who are visually impaired. Thus it is important for clinicians and policy makers alike to understand how various study designs and measurement methods should be interpreted so that the conclusions and recommendations they make are not overly broad, too narrowly constrained, or even misguided. We offer a methodological framework to guide interpretations of studies on vision and driving that can also serve as a heuristic for researchers in the area. Here, we discuss research designs and general measurement methods for the study of vision as they relate to driver safety, driver performance, and driver-centered (self-reported) outcomes.

Peripheral prism glasses: effects of moving and stationary backgrounds

PURPOSE

Unilateral peripheral prisms for homonymous hemianopia (HH) expand the visual field through peripheral binocular visual confusion, a stimulus for binocular rivalry that could lead to reduced predominance and partial suppression of the prism image, thereby limiting device functionality. Using natural-scene images and motion videos, we evaluated whether detection was reduced in binocular compared with monocular viewing.

METHODS

Detection rates of nine participants with HH or quadranopia and normal binocularity wearing peripheral prisms were determined for static checkerboard perimetry targets briefly presented in the prism expansion area and the seeing hemifield. Perimetry was conducted under monocular and binocular viewing with targets presented over videos of real-world driving scenes and still frame images derived from those videos.

RESULTS

With unilateral prisms, detection rates in the prism expansion area were significantly lower in binocular than in monocular (prism eye) viewing on the motion background (medians, 13 and 58%, respectively, p = 0.008) but not the still frame background (medians, 63 and 68%, p = 0.123). When the stimulus for binocular rivalry was reduced by fitting prisms bilaterally in one HH and one normally sighted subject with simulated HH, prism-area detection rates on the motion background were not significantly different (p > 0.6) in binocular and monocular viewing.

CONCLUSIONS

Conflicting binocular motion appears to be a stimulus for reduced predominance of the prism image in binocular viewing when using unilateral peripheral prisms. However, the effect was only found for relatively small targets. Further testing is needed to determine the extent to which this phenomenon might affect the functionality of unilateral peripheral prisms in more real-world situations.

An assessment of driving fitness in patients with visual impairment to understand the elevated risk of motor vehicle accidents

OBJECTIVE

To assess the driving fitness of patients with glaucoma by identifying specific areas and degrees of visual field impairment that threaten safe driving.

DESIGN

Case-control study.

SETTING, AND PARTICIPANTS

This prospective study included 36 patients with advanced glaucoma, defined as Humphrey field analyzer (HFA; 24-2 SITA standard program) measurements of mean deviation in both eyes of worse than -12 dB, and 36 age-matched and driving exposure time-matched normal subjects. All participants underwent testing in a novel driving simulator (DS) system. Participants were recruited between September 2010 and January 2012.

MAIN OUTCOME MEASURES

The number of collisions with simulated hazards and braking response time in 14 DS scenarios was recorded. Monocular HFA 24-2 test results from both eyes were merged to calculate the binocular integrated visual field (IVF). The position of the IVF subfields in which the collision-involved patients had lower sensitivity than the collision-uninvolved patients was compared with the track of the hazard. The cut-off value to predict an elevated risk of collisions was determined, as were its sensitivity and specificity, with the area under the receiver operating characteristic (AUROC) curve.

RESULTS

Patients with advanced glaucoma were involved in a significantly higher number of collisions in the DS than the age-matched and driving exposure time-matched normal subjects (119 vs 40, respectively, p<0.0001), especially in four specific DS scenarios. In these four scenarios, IVF sensitivity was significantly lower in the collision-involved patients than in the collision-uninvolved patients in subfields on or near the track of the simulated hazard (p<0.05). The subfields with the largest AUROC curve had values ranging from 0.72 to 0.91 and were located in the paracentral visual field just below the horizontal.

CONCLUSIONS

Our novel DS system effectively assessed visual impairment, showing that simulators may have future potential in educating patients.

Driving with homonymous visual field loss: Does visual search performance predict hazard detection?

Introduction

Stroke often causes homonymous visual field loss, which can lead to exclusion from driving. Retention of a driving licence is sometimes possible by completing an on-road assessment, but this is not practical for all. It is important to find simple tests that can inform the assessment and rehabilitation of driving-related visual-motor function.

Method

We developed novel computerised assessments: visual search; simple reaction and decision reaction to appearing pedestrians; and pedestrian detection during simulated driving. We tested 12 patients with stroke (seven left, five right field loss) and 12 controls.

Results

The homonymous visual field defect group was split into adequately compensated or inadequately compensated groups based on visual search performance. The inadequately compensated group had problems with stimuli in their affected field: they tended to react more slowly than controls and in the driving task they failed to detect a number of pedestrians. In contrast, the adequately compensated group were better at detecting pedestrians, though reaction times were slightly slower than controls.

Conclusion

We suggest that our search task can predict, to a limited extent, whether a person with stroke compensates for visual field loss, and may potentially identify suitability for specific rehabilitation to promote return to driving.

Role of inter-hemispheric transfer in generating visual evoked potentials in V1-damaged brain hemispheres

Partial cortical blindness is a visual deficit caused by unilateral damage to the primary visual cortex, a condition previously considered beyond hopes of rehabilitation. However, recent data demonstrate that patients may recover both simple and global motion discrimination following intensive training in their blind field. The present experiments characterized motion-induced neural activity of cortically blind (CB) subjects prior to the onset of visual rehabilitation. This was done to provide information about visual processing capabilities available to mediate training-induced visual improvements. Visual Evoked Potentials (VEPs) were recorded from two experimental groups consisting of 9 CB subjects and 9 age-matched, visually-intact controls. VEPs were collected following lateralized stimulus presentation to each of the 4 visual field quadrants. VEP waveforms were examined for both stimulus-onset (SO) and motion-onset (MO) related components in postero-lateral electrodes. While stimulus presentation to intact regions of the visual field elicited normal SO-P1, SO-N1, SO-P2 and MO-N2 amplitudes and latencies in contralateral brain regions of CB subjects, these components were not observed contralateral to stimulus presentation in blind quadrants of the visual field. In damaged brain hemispheres, SO-VEPs were only recorded following stimulus presentation to intact visual field quadrants, via inter-hemispheric transfer. MO-VEPs were only recorded from damaged left brain hemispheres, possibly reflecting a native left/right asymmetry in inter-hemispheric connections. The present findings suggest that damaged brain hemispheres contain areas capable of responding to visual stimulation. However, in the absence of training or rehabilitation, these areas only generate detectable VEPs in response to stimulation of the intact hemifield of vision.

Compensatory eye and head movements of patients with homonymous hemianopia in the naturalistic setting of a driving simulation

Homonymous hemianopia (HH) is a frequent deficit resulting from lesions to post-chiasmal brain structures with a significant negative impact on activities of daily living. To address the question how patients with HH may compensate their visual field defect in a naturalistic environment, we performed a driving simulation experiment and quantitatively analyzed both eye and head movements using a head-mounted pupil camera. 14 patients with HH and 14 matched healthy control subjects participated in the study. Based on the detection performance of dynamically moving obstacles, which appeared unexpectedly along the sides of the road track, we divided the patient group into a high- and a low-performance group. Then, we compared parameters of eye and head movements between the two patient groups and the matched healthy control group to identify those which mediate successful detection of potentially hazardous objects. Differences in detection rates could not be explained by demographic variables or the extent of the visual field defect. Instead, high performance of patients with HH in the naturalistic setting of our driving simulation depended on an adapted visual exploratory behavior characterized by a relative increase in the amplitude and a corresponding increase in the peak velocity of saccades, widening horizontally the distribution of eye movements, and by a shift of the overall distribution of saccades into the blind hemifield. The result of the group comparison analyses was confirmed by a subsequent stepwise regression analysis which identified the horizontal spread of eye movements as single factor predicting the detection of hazardous objects.

Homonymous Visual Field Loss and Its Impact on Visual Exploration: A Supermarket Study

PURPOSE

Homonymous visual field defects (HVFDs) may critically interfere with quality of life. The aim of this study was to assess the impact of HVFDs on a supermarket search task and to investigate the influence of visual search on task performance.

METHODS

Ten patients with HVFDs (four with a right-sided [HR] and six with a left-sided defect [HL]), and 10 healthy-sighted, sex-, and age-matched control subjects were asked to collect 20 products placed on two supermarket shelves as quickly as possible. Task performance was rated as "passed" or "failed" with regard to the time per correctly collected item (T_C -failed = 4.84 seconds based on the performance of healthy subjects). Eye movements were analyzed regarding the horizontal gaze activity, glance frequency, and glance proportion for different VF areas.

RESULTS

Seven of 10 HVFD patients (three HR, four HL) passed the supermarket search task. Patients who passed needed significantly less time per correctly collected item and looked more frequently toward the VFD area than patients who failed. HL patients who passed the test showed a higher percentage of glances beyond the 60° VF (P < 0.05).

CONCLUSION

A considerable number of HVFD patients performed successfully and could compensate for the HVFD by shifting the gaze toward the peripheral VF and the VFD area.

TRANSLATIONAL RELEVANCE

These findings provide new insights on gaze adaptations in patients with HVFDs during activities of daily living and will enhance the design and development of realistic examination tools for use in the clinical setting to improve daily functioning. (http://www.clinicaltrials.gov, NCT01372319, NCT01372332).

Patients with homonymous hemianopia become visually qualified to drive using novel monocular sector prisms

Patients with homonymous hemianopia (HH) often fail to meet visual field (VF) requirements for a driver's license. We describe 2 patients with complete HH, who met the minimum VF requirements for driving using a novel, high-power, monocular sector prism system. Baseline VFs were assessed using automated and kinetic perimetry. Patients were fitted with glasses and press-on 57-PD peripheral monocular sector prisms placed on the lens ipsilateral to the VF defect above and below the visual axis with prisms oriented obliquely. Kinetic perimetry was reassessed both monocularly and binocularly, with and without prisms. The 2 patients had 95° and 82° angle of continuous, horizontal, binocular VF. With the use of the prism system, the binocular VF increased to 115° and 112° angles. Both patients reported improvement in quality of life and each holds a valid driver's license and has successfully operated a motor vehicle without any restrictions or accidents. These findings suggest that the addition of oblique 57-PD prisms to the ipsilateral spectacle lens above and below the visual axis for patients with complete HH can significantly increase horizontal VF, which may help an individual become visually qualified to obtain a driver's license.

Homonymous hemianopia: challenges and solutions

Stroke is the most common cause of homonymous hemianopia (HH) in adults, followed by trauma and tumors. Associated signs and symptoms, as well as visual field characteristics such as location and congruity, can help determine the location of the causative brain lesion. HH can have a significant effect on quality of life, including problems with driving, reading, or navigation. This can result in decreased independence, inability to enjoy leisure activities, and injuries. Understanding these restrictions, as well as the management options, can aid in making the best use of remaining vision. Treatment options include prismatic correction to expand the remaining visual field, compensatory training to improve visual search abilities, and vision restoration therapy to improve the vision itself. Spontaneous recovery can occur within the first months. However, because spontaneous recovery does not always occur, methods of reducing visual disability play an important role in the rehabilitation of patients with HH.

Randomized crossover clinical trial of real and sham peripheral prism glasses for hemianopia

IMPORTANCE

There is a major lack of randomized controlled clinical trials evaluating the efficacy of prismatic treatments for hemianopia. Evidence for their effectiveness is mostly based on anecdotal case reports and open-label evaluations without a control condition.

OBJECTIVE

To evaluate the efficacy of real relative to sham peripheral prism glasses for patients with complete homonymous hemianopia.

DESIGN, SETTING, AND PARTICIPANTS

Double-masked, randomized crossover trial at 13 study sites, including the Peli laboratory at Schepens Eye Research Institute, 11 vision rehabilitation clinics in the United States, and 1 in the United Kingdom. Patients were 18 years or older with complete homonymous hemianopia for at least 3 months and without visual neglect or significant cognitive decline.

INTERVENTION

Patients were allocated by minimization into 2 groups. One group received real (57-prism diopter) oblique and sham (<5-prism diopter) horizontal prisms; the other received real horizontal and sham oblique, in counterbalanced order. Each crossover period was 4 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was the overall difference, across the 2 periods of the crossover, between the proportion of participants who wanted to continue with (said yes to) real prisms and the proportion who said yes to sham prisms. The secondary outcome was the difference in perceived mobility improvement between real and sham prisms.

RESULTS

Of 73 patients randomized, 61 completed the crossover. A significantly higher proportion said yes to real than sham prisms (64% vs 36%; odds ratio, 5.3; 95% CI, 1.8-21.0). Participants who continued wear after 6 months reported greater improvement in mobility with real than sham prisms at crossover end (P = .002); participants who discontinued wear reported no difference.

CONCLUSIONS AND RELEVANCE

Real peripheral prism glasses were more helpful for obstacle avoidance when walking than sham glasses, with no differences between the horizontal and oblique designs. Peripheral prism glasses provide a simple and inexpensive mobility rehabilitation intervention for hemianopia.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00494676.

Driving simulators for occupational therapy screening, assessment, and intervention

Simulation technology provides safe, objective, and repeatable performance measures pertaining to operational (e.g., avoiding a collision) or tactical (e.g., lane maintenance) driver behaviors. Many occupational therapy researchers and others are using driving simulators to test a variety of applications across diverse populations. A growing body of literature provides support for associations between simulated driving and actual on-road driving. One limitation of simulator technology is the occurrence of simulator sickness, but management strategies exist to curtail or mitigate its onset. Based on the literature review and a consensus process, five consensus statements are presented to support the use of driving simulation technology among occupational therapy practitioners. The evidence suggests that by using driving simulators occupational therapy practitioners may detect underlying impairments in driving performance, identify driving errors in at-risk drivers; differentiate between driving performance of impaired and healthy controls groups; show driving errors with absolute and relative validity compared to on-road studies; and mitigate the onset of simulator sickness. Much progress has been made among occupational therapy researchers and practitioners in the use of driving simulation technology; however, empirical support is needed to further justify the use of driving simulators in clinical practice settings as a valid, reliable, clinical useful, and cost effective tool for driving assessment and intervention.

Driving with hemianopia: IV. Head scanning and detection at intersections in a simulator

PURPOSE

Using a driving simulator, we examined the effects of homonymous hemianopia (HH) on head scanning behaviors at intersections and evaluated the role of inadequate head scanning in detection failures.

METHODS

Fourteen people with complete HH and without cognitive decline or visual neglect and 12 normally sighted (NV) current drivers participated. They drove in an urban environment following predetermined routes, which included multiple intersections. Head scanning behaviors were quantified at T-intersections (n = 32) with a stop or yield sign. Participants also performed a pedestrian detection task. The relationship between head scanning and detection was examined at 10 intersections.

RESULTS

For HH drivers, the first scan was more likely to be toward the blind than the seeing hemifield. They also made a greater proportion of head scans overall to the blind side than did the NV drivers to the corresponding side (P = 0.003). However, head scan magnitudes of HH drivers were smaller than those of the NV group (P < 0.001). Drivers with HH had impaired detection of blind-side pedestrians due either to not scanning in the direction of the pedestrian or to an insufficient scan magnitude (left HH detected only 46% and right HH 8% at the extreme left and right of the intersection, respectively).

CONCLUSIONS

Drivers with HH demonstrated compensatory head scan patterns, but not scan magnitudes. Inadequate scanning resulted in blind-side detection failures, which might place HH drivers at increased risk for collisions at intersections. Scanning training tailored to specific problem areas identified in this study might be beneficial.

Visual attention measures predict pedestrian detection in central field loss: a pilot study

PURPOSE

The ability of visually impaired people to deploy attention effectively to maximize use of their residual vision in dynamic situations is fundamental to safe mobility. We conducted a pilot study to evaluate whether tests of dynamic attention (multiple object tracking; MOT) and static attention (Useful Field of View; UFOV) were predictive of the ability of people with central field loss (CFL) to detect pedestrian hazards in simulated driving.

METHODS

11 people with bilateral CFL (visual acuity 20/30-20/200) and 11 age-similar normally-sighted drivers participated. Dynamic and static attention were evaluated with brief, computer-based MOT and UFOV tasks, respectively. Dependent variables were the log speed threshold for 60% correct identification of targets (MOT) and the increase in the presentation duration for 75% correct identification of a central target when a concurrent peripheral task was added (UFOV divided and selective attention subtests). Participants drove in a simulator and pressed the horn whenever they detected pedestrians that walked or ran toward the road. The dependent variable was the proportion of timely reactions (could have stopped in time to avoid a collision).

RESULTS

UFOV and MOT performance of CFL participants was poorer than that of controls, and the proportion of timely reactions was also lower (worse) (84% and 97%, respectively; p = 0.001). For CFL participants, higher proportions of timely reactions correlated significantly with higher (better) MOT speed thresholds (r = 0.73, p = 0.01), with better performance on the UFOV divided and selective attention subtests (r = -0.66 and -0.62, respectively, p<0.04), with better contrast sensitivity scores (r = 0.54, p = 0.08) and smaller scotomas (r = -0.60, p = 0.05).

CONCLUSIONS

Our results suggest that brief laboratory-based tests of visual attention may provide useful measures of functional visual ability of individuals with CFL relevant to more complex mobility tasks.

Driving with binocular visual field loss? A study on a supervised on-road parcours with simultaneous eye and head tracking

Post-chiasmal visual pathway lesions and glaucomatous optic neuropathy cause binocular visual field defects (VFDs) that may critically interfere with quality of life and driving licensure. The aims of this study were (i) to assess the on-road driving performance of patients suffering from binocular visual field loss using a dual-brake vehicle, and (ii) to investigate the related compensatory mechanisms. A driving instructor, blinded to the participants' diagnosis, rated the driving performance (passed/failed) of ten patients with homonymous visual field defects (HP), including four patients with right (HR) and six patients with left homonymous visual field defects (HL), ten glaucoma patients (GP), and twenty age and gender-related ophthalmologically healthy control subjects (C) during a 40-minute driving task on a pre-specified public on-road parcours. In order to investigate the subjects' visual exploration ability, eye movements were recorded by means of a mobile eye tracker. Two additional cameras were used to monitor the driving scene and record head and shoulder movements. Thus this study is novel as a quantitative assessment of eye movements and an additional evaluation of head and shoulder was performed. Six out of ten HP and four out of ten GP were rated as fit to drive by the driving instructor, despite their binocular visual field loss. Three out of 20 control subjects failed the on-road assessment. The extent of the visual field defect was of minor importance with regard to the driving performance. The site of the homonymous visual field defect (HVFD) critically interfered with the driving ability: all failed HP subjects suffered from left homonymous visual field loss (HL) due to right hemispheric lesions. Patients who failed the driving assessment had mainly difficulties with lane keeping and gap judgment ability. Patients who passed the test displayed different exploration patterns than those who failed. Patients who passed focused longer on the central area of the visual field than patients who failed the test. In addition, patients who passed the test performed more glances towards the area of their visual field defect. In conclusion, our findings support the hypothesis that the extent of visual field per se cannot predict driving fitness, because some patients with HVFDs and advanced glaucoma can compensate for their deficit by effective visual scanning. Head movements appeared to be superior to eye and shoulder movements in predicting the outcome of the driving test under the present study scenario.