Posts Tagged visual rehabilitation

[BLOG] Visual effects of stroke often undetected

Every year, nearly 800,000 Americans suffer a stroke, according to the Internet Stroke Center.

Strokes are a leading cause of death and disability, but what many people don’t realize is that two out of three stroke survivors will also experience visual impairments related to their stroke (Rowe). These can include diminished central or peripheral vision, eye movement abnormalities or visual perceptual defects.

Sadly, it is not uncommon for me to see patients who are still struggling with undiagnosed vision problems months or even years after a stroke. There are a number of reasons for this. In the immediate days and weeks after a stroke, patients and their families and doctors are often most concerned about preventing brain hemorrhages and addressing motor and language deficits. After that, patients may have difficulty articulating their symptoms or may not be aware that balance issues are connected to vision. In some cases, they may have been examined and incorrectly told that nothing can be done.

Given the prevalence of post-stroke visual impairment, anyone who suffers a stroke should be seen by an eye care specialist as soon as possible and, ideally, be referred to a neuro-optometric rehabilitation optometrist. Visual rehabilitation can lead to greater independence and improved quality of life and can accelerate the success of other therapies. In fact, most stroke survivors need more than one type of rehabilitation, so it is not unusual for me to work with a team of speech, occupational or physical therapists to help the stroke survivor learn new ways of performing tasks to circumvent or compensate for any residual disabilities.

The most common visual complication of stroke is a homonymous hemianopsia, or a visual field defect on the same side in each eye, resulting from damage to the occipital lobe, where the majority of visual processing takes place. This type of stroke-related field loss is often accompanied by a visual midline shift, which occurs when there is a mismatch between visual spatial information and the patient’s proprioceptive base of support.

A shift in the visual midline can directly affect posture, balance and spatial orientation, and it significantly increases the risk of falls. It is relatively easy to diagnose: Just ask a patient to walk down the hall and observe whether they drift to one side or tip backwards or forwards. In a study that I co-authored with Dr. William Padula, we showed that intervention with yoked prisms can restore the visual midline, thereby improving balance and reducing the risk of falls and subsequent injury.

Strokes that affect other parts of the brain may result in cranial nerve damage-associated diplopia or the rare but fascinating phenomenon of visual neglect, in which the patient completely loses awareness of one side of the body. In less severe cases, there can also be subtle effects on eye tracking and teaming, leading to impaired saccades and pursuits or convergence insufficiency. These impairments can be improved with vision rehabilitation and prism lenses.

Vision rehabilitation may not always be able to fully restore patients to the same degree of visual function they had before the stroke, but we can go a long way towards improving quality of life and helping patients maximize the vision they have.


Internet Stroke Center. U.S. Stroke Statistics. Accessed January 16, 2019.

Padula WV, et al. NeuroRehabilitation. 2015;doi:10.3233/NRE-151263.

Rowe FJ. Brain Behav. 2017;doi:10.1002/brb3.778.


via BLOG: Visual effects of stroke often undetected

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[ARTICLE] Audiovisual Rehabilitation in Hemianopia: A Model-Based Theoretical Investigation – Full Text

Hemianopic patients exhibit visual detection improvement in the blind field when audiovisual stimuli are given in spatiotemporally coincidence. Beyond this “online” multisensory improvement, there is evidence of long-lasting, “offline” effects induced by audiovisual training: patients show improved visual detection and orientation after they were trained to detect and saccade toward visual targets given in spatiotemporal proximity with auditory stimuli. These effects are ascribed to the Superior Colliculus (SC), which is spared in these patients and plays a pivotal role in audiovisual integration and oculomotor behavior. Recently, we developed a neural network model of audiovisual cortico-collicular loops, including interconnected areas representing the retina, striate and extrastriate visual cortices, auditory cortex, and SC. The network simulated unilateral V1 lesion with possible spared tissue and reproduced “online” effects. Here, we extend the previous network to shed light on circuits, plastic mechanisms, and synaptic reorganization that can mediate the training effects and functionally implement visual rehabilitation. The network is enriched by the oculomotor SC-brainstem route, and Hebbian mechanisms of synaptic plasticity, and is used to test different training paradigms (audiovisual/visual stimulation in eye-movements/fixed-eyes condition) on simulated patients. Results predict different training effects and associate them to synaptic changes in specific circuits. Thanks to the SC multisensory enhancement, the audiovisual training is able to effectively strengthen the retina-SC route, which in turn can foster reinforcement of the SC-brainstem route (this occurs only in eye-movements condition) and reinforcement of the SC-extrastriate route (this occurs in presence of survived V1 tissue, regardless of eye condition). The retina-SC-brainstem circuit may mediate compensatory effects: the model assumes that reinforcement of this circuit can translate visual stimuli into short-latency saccades, possibly moving the stimuli into visual detection regions. The retina-SC-extrastriate circuit is related to restitutive effects: visual stimuli can directly elicit visual detection with no need for eye movements. Model predictions and assumptions are critically discussed in view of existing behavioral and neurophysiological data, forecasting that other oculomotor compensatory mechanisms, beyond short-latency saccades, are likely involved, and stimulating future experimental and theoretical investigations.


The primary human visual pathway conveys the majority of retinal fibers to the lateral geniculate nucleus of the thalamus and then, via the optic radiations, to the primary visual cortex (V1) (the retino-geniculo-striate pathway). V1 is the main distributor of visual information to extrastriate visual areas, for further processing. A secondary visual pathway (the retino-collicular pathway) routes a minority of retinal fibers directly to the Superior Colliculus (a midbrain structure), which also has reciprocal connections with striate and extrastriate visual cortices (May, 2006).

Patients with lateralized damages to the primary visual cortex (V1) or to the neural pathway feeding V1 often develop homonymous hemianopia, a visual field defect with the loss of conscious vision in one hemifield. Hemianopic patients cannot perceive visual stimuli presented in the blind hemifield; moreover, they show the inability to spontaneously develop effective oculomotor strategies to compensate for the visual field loss (Hildebrandt et al., 1999Zihl, 2000Tant et al., 2002).

Despite the visual deficit, hemianopic patients can preserve the ability to integrate audiovisual stimuli in the affected field, with beneficial effects (Frassinetti et al., 2005Leo et al., 2008). In particular, data by Frassinetti and colleagues (Frassinetti et al., 2005) show that patients performing a visual detection task, while maintaining central fixation, significantly improved conscious visual detections in the affected field, when the auditory stimuli were applied in spatial and temporal coincidence with the visual targets.

The Superior Colliculus is the most likely structure mediating this multisensory improvement, because of its anatomical connections and the properties of its neuronal responses. Indeed, SC neurons receive not only visual information but also signals from other different sensory modalities, such as audition (Meredith and Stein, 1986Stein and Meredith, 1993May, 2006). Visual and auditory information are integrated in multisensory SC neurons according to specific principles (Stein and Meredith, 1993): an audiovisual stimulation elicits a stronger neuronal activation than each single component, when the visual and auditory components are presented in spatial and temporal register (spatial and temporal principle). Moreover, a proportionally greater enhancement of multisensory neuronal activation is evoked when weakly effective unisensory stimuli are combined, compared to the combination of highly effective stimuli (inverse effectiveness principle). The SC integrative principles have strong implications in hemianopia, as the SC and the retino-collicular pathway are preserved in these patients. Visual retinal input to SC, although weak, can still be efficiently combined with an accessory auditory input thanks to the inverse effectiveness principle, provided the rule of spatial and temporal proximity is satisfied. Furthermore, SC multisensory enhancement can affect cortical visual processing thanks to the projections from the SC to the visual cortices.

In addition to the immediate, “online” multisensory improvement in visual detection, there is also evidence of prolonged, “offline” effects that can be induced by repeated exposure to audiovisual stimuli. Indeed, long-lasting improvements of visual performances in hemianopic patients, promoted by audiovisual training protocols stimulating the blind hemifield, have been reported (Bolognini et al., 2005Passamonti et al., 2009Dundon et al., 2015bTinelli et al., 2015Grasso et al., 2016). During the training, a visual target was given in close spatial and temporal proximity with an auditory stimulus, at various positions in the visual field; patients were asked to detect the presence of the visual target, by directing the gaze toward it from a central fixation point. Results revealed a significant post-training improvement in detection of unimodal visual targets in the blind field when the patients were allowed to use eye movements, while a weak amelioration was found when they had to maintain central fixation (Bolognini et al., 2005Tinelli et al., 2015). Such results suggest that the audiovisual training could promote an increased oculomotor response to visual stimuli in the affected hemifield.

Beyond the “online” effects of audiovisual stimulation, the Superior Colliculus is a possible candidate for mediating the training effects, too. Indeed, the SC projects to brainstem motor areas controlling eyes and head orientation, and is critically involved in the initiation and execution of reflexive (i.e., exogenously-driven) saccades (Sparks, 1986Jay and Sparks, 1987aMay, 2006Johnston and Everling, 2008). Importantly, more than 70% of SC neurons projecting to the brainstem and, therefore involved in saccade generation, respond to multisensory stimulations (Meredith and Stein, 1986). As such, audiovisual stimuli, enhancing multisensory SC activation, might plastically reinforce the gain of the transduction from the SC sensory response to the motor output; in other words, after training the oculomotor system could have acquired increased responsiveness to the visual input conveyed via the retino-collicular pathway. However, the plastic mechanisms and synaptic reorganization that can functionally instantiate these visuomotor capabilities remain undetermined. Moreover, it is unclear whether the training may even stimulate genuine visual restitution beyond oculomotor compensation, and how the compensatory and restitutive effects may complementary contribute to visual improvements.

Recently, we have developed a neural network model (Magosso et al., 2016) that formalized the main cortico-collicular loops involved in audiovisual integration, and implemented—via neural connections and input-output neural characteristics—the SC multisensory integrative principles. The network postulated neural correlates of visual consciousness and mimicked unilateral V1 lesion. Simulations, performed in fixed-eyes condition, reproduced the “online” effects of enhanced visual detection under audiovisual stimulation.

Here, we extend our previous neural network to explore the effects of training in simulated hemianopic patients, providing quantitative predictions that can contribute to a mechanistic understanding of visual performance improvement observed in real patients. To this aim, the network has been integrated by novel elements. First, we have included a module of saccade generation, embracing the colliculus sensory-motor transduction; in this way, we can account for the potentiality of short-latency saccades triggered in a bottom-up fashion. Second, Hebbian mechanisms of synaptic learning have been implemented and adopted during training simulations. Different training paradigms (audiovisual multisensory/visual unisensory stimulation in eye-movements/fixed-eyes condition) are tested, to examine their efficacy in promoting different forms of rehabilitation (compensatory/restitutive), and to assess the predicted results in light of in vivo data.


Materials and Methods

The neural network is conceptually made up of two modules (Figure 1A). A sensory module (blue blocks and lines) includes cortical and subcortical (SC) neuronal areas devoted to the sensory representation of the external stimulation. An oculomotor module (red blocks and lines) can potentially react to the sensory neural representation, generating a saccade toward the external stimulation. The SC is involved in both modules.

Figure 1. (A) Sketch of the neural network architecture. Blue blocks and lines represent the sensory module; red blocks and lines denote the oculomotor module. R, retina; V1, primary visual cortex; E, extrastriate visual cortex; SC, Superior Colliculus; A, auditory area; FP, saccade-related frontoparietal areas (δ denotes a pure delay); SG, Brainstem Saccade Generator. g(t) is the current gaze position (resulting from the oculomotor module); θg is the target gaze position decoded from the SC activity. pis the position of the external (visual or spatially coincident audiovisual) stimulus in head-centered coordinates, and p-g(t) is the stimulus position in retinotopic coordinates. WH, Q denotes inter-area synapses from neurons in area Q to neurons in area H(B) Exemplary pattern of basal (i.e., pre-training) inter-area synapses. Here, synapses WSC, R from the retina to SC are depicted, limited to about one hemifield (−10° ÷ +90°) (the same pattern holds for the remaining not shown positions). x-axis reports the position (j, in deg) of the pre-synaptic neuron in area R and the y-axis the position (i, in deg) of the post-synaptic neuron in area SC. The color at each intersection (j, i) codes the strength of the synapse from the pre-synaptic neuron j in area R to the post-synaptic neuron i in SC. Similar patterns hold for all other inter-area synapses within the sensory module. Consistently with the following figures, scale color is between 0 and the maximum value reachable by training (WSC,RmaxWmaxSC,R). WSC,R0W0SC,R denotes the central weight of the pre-training Gaussian pattern of the synapses. (C) Schematic picture of the eye-centered topological organization of neurons in each area. In case (1), the stimulus induces an activation bubble centered on the neuron with preferred retinal position = 45°, in a given area; in case (2), the stimulus induces an activation bubble centered on the neuron with preferred retinal position = 45°–30° = 15°.

Continue —> Frontiers | Audiovisual Rehabilitation in Hemianopia: A Model-Based Theoretical Investigation | Frontiers in Computational Neuroscience

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[Abstract] Homonymous Hemianopia and Vision Restoration Therapy

Homonymous hemianopia from stroke causes visual disability. Although some patients experience spontaneous improvement, others have limited to no change and may be left with a severe disability. Current rehabilitation strategies are compensatory and cannot restore function. Animal studies suggest that central nervous system plasticity could allow for redirection of lost visual function into undamaged areas of cortex. A commercial therapy system was developed, from which claims of visual field expansion were disputed by independent researchers. The treatment remains controversial with seemingly contradictory data being generated. Continued research is underway to demonstrate the (non-)efficacy of this treatment method.

Source: Homonymous Hemianopia and Vision Restoration Therapy – Neurologic Clinics

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[ARTICLE] Compensatory Recovery after Multisensory Stimulation in Hemianopic Patients: Behavioral and Neurophysiological Components – Full Text

Lateralized post-chiasmatic lesions of the primary visual pathway result in loss of visual perception in the field retinotopically corresponding to the damaged cortical area. However, patients with visual field defects have shown enhanced detection and localization of multisensory audio-visual pairs presented in the blind field. This preserved multisensory integrative ability (i.e., crossmodal blindsight) seems to be subserved by the spared retino-colliculo-dorsal pathway. According to this view, audio-visual integrative mechanisms could be used to increase the functionality of the spared circuit and, as a consequence, might represent an important tool for the rehabilitation of visual field defects. The present study tested this hypothesis, investigating whether exposure to systematic multisensory audio-visual stimulation could induce long-lasting improvements in the visual performance of patients with visual field defects. A group of 10 patients with chronic visual field defects were exposed to audio-visual training for 4 h daily, over a period of 2 weeks. Behavioral, oculomotor and electroencephalography (EEG) measures were recorded during several visual tasks before and after audio-visual training. After audio-visual training, improvements in visual search abilities, visual detection, self-perceived disability in daily life activities and oculomotor parameters were found, suggesting the implementation of more effective visual exploration strategies. At the electrophysiological level, after training, patients showed a significant reduction of the P3 amplitude in response to stimuli presented in the intact field, reflecting a reduction in attentional resources allocated to the intact field, which might co-occur with a shift of spatial attention towards the blind field. More interestingly, both the behavioral improvements and the electrophysiological changes observed after training were found to be stable at a follow-up session (on average, 8 months after training), suggesting long-term effects of multisensory audio-visual training. These long-lasting effects seem to be subserved by the activation of the spared retino-colliculo-dorsal pathway, which promotes orienting responses towards the blind field, able to both compensate for the visual field loss and concurrently attenuate visual attention towards the intact field. These results add to previous findings the knowledge that audio-visual multisensory stimulation promote long-term plastic changes in hemianopics, resulting in stable and long-lasting ameliorations in behavioral and electrophysiological measures.


Visual field defects, resulting from damage to the visual structures located behind the chiasma, including primary visual cortex (V1), surrounding extrastriate cortices and optic radiations, consist of a loss of visual perception in up to one half of the visual field. Patients with visual field defects cannot see a visual stimulus presented within the blind area of the visual field. Although the ability to consciously perceive visual stimuli presented in the blind field is lost, these hemianopic patients have demonstrated the specific ability to implicitly detect or discriminate certain visual features of stimuli presented in the blind field, such as motion, color and orientation (Weiskrantz et al., 1974), as well as the emotional content of the visual signals (affective blindsight; De Gelder et al., 1999; Morris et al., 2001; Pegna et al., 2005; Bertini et al., 2013; Cecere et al., 2014). These patients can also integrate unseen visual stimuli with auditory information (crossmodal blindsight; Leo et al., 2008b). The neuronal structures and pathways sustaining implicit processing of visual signals following damage to V1 or the neural pathway feeding V1 are still under debate; this topic is very relevant for the rehabilitation of visual field defects, because the same pathways could mediate recovery of the deficit, if adequately boosted.

Continue —> Frontiers | Compensatory Recovery after Multisensory Stimulation in Hemianopic Patients: Behavioral and Neurophysiological Components | Frontiers in Systems Neuroscience

Figure 2. Axial views of CT/MRI scans of the patients. L = left, R = right.

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[ARTICLE] Vision problems in ischaemic stroke patients: effects on life quality and disability – European Journal of Neurology – Full Text HTML


Background and purpose Vision problems after cerebral infarction are an increasingly acknowledged problem. Our aim was to investigate the effect on quality of life and post-stroke disability.

Methods Patients admitted to the Stroke Unit, Department of Neurology, Haukeland University Hospital, between February 2006 and July 2008 with acute cerebral infarction were prospectively registered in the NORSTROKE Registry. Patients received a postal questionnaire at least 6 months after stroke. The questionnaire included 15D©, EuroQol 5D (EQ-5D™), the Hospital Anxiety and Depression Scale (HADS), the Fatigue Severity Scale (FSS) and the Barthel Index (BI).

Results Of 328 responders, 83 (25.4%) reported a vision problem. Vision problems were associated with older age (71.8 years vs. 66.5 years, P = 0.001), higher National Institutes of Health Stroke Scale score on admission (5.9 vs. 3.8, P < 0.001), higher modified Rankin Scale day 7 (2.0 vs. 1.4, P < 0.001) and lower BI day 7 (85.7 vs. 93.9, P = 0.002). Patients with vision problems had lower median EQ-5D utility score (0.62 vs. 0.80, P < 0.001), lower median 15D utility score (0.73 vs. 0.89, P < 0.001), higher median HADS score (12 vs. 5, P < 0.001), higher median FSS score (5.6 vs. 4.3, P < 0.001) and lower median BI (95 vs. 100, P < 0.001) on long-term follow-up. Patients with self-reported vision problems scored lower on all sub-scores of BI on follow-up (all P < 0.001).

Conclusion One in four patients reported a vision problem on follow-up after cerebral infarction. Vision problems after cerebral infarction reduce quality of life and are associated with increased disability. Thorough diagnostic evaluation and targeted rehabilitation is important.

Continue: —>  Vision problems in ischaemic stroke patients: effects on life quality and disability – Sand – 2015 – European Journal of Neurology – Wiley Online Library


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[Editorial] Neural bases of binocular vision and coordination and their implications in visual training programs


To see or not to see? That is the question of this research topic. How do human beings see not with their eyes but with their brain, which lies in a moving body, itself evolving in a continuously changing environment? What and how do humans see in the context of a particular task at a given moment? How do humans cease to see after some damage in the brain or neurofunctional disorder? And how may the basic science of eye movements and vision help to develop efficient visual training programs?

The present research topic, entitled Neural bases of binocular vision and coordination and their implications in visual training programs, aims at putting forward our knowledge of the neural underpinnings of vision in its motor, sensory, cognitive, emotional and vegetative expressions. It does not target an exhaustive collection of what we know in the field of visual neurosciences. For that purpose, the reader may refer to the volume sets by Chalupa and Werner (2003). Rather, this research topic focuses on the latest findings on the neural aspects of eye movements and visual perception that directly help to understand and improve visual training programs in pathological conditions. Such disorders follow damages of the cerebral visual pathways (e.g., hemianopia) or refer to syndromes hitherto believed to be peripheral but in which neurophysiology and brain imaging are uncovering neural correlates or causes (e.g., amblyopia).

The research topic is divided into three parts respectively dedicated to eye movements, visual perception, and visual training programs, each having six chapters, and starts with an overview. In the introductory chapter, Coubard, Urbanski, Bourlon and Gaumet (2014) remind the reader of the importance of action in visual processing before describing the cascade of physiological mechanisms underlying eye movements, followed by a description of the five main neurovisual systems. After an overview of pathological conditions causing not eye but brain blindness – also called neurovisual disorders – the authors end by describing the disciplines of visual rehabilitation.

Continue —>  Frontiers | Editorial: Neural bases of binocular vision and coordination and their implications in visual training programs | Frontiers in Integrative Neuroscience.

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[ARTICLE] A study on the natural history of scanning behaviour in patients with visual field defects after stroke – Full Text PDF



A visual field defect (VFD) is a common consequence of stroke with a detrimental effect upon the survivors’ functional ability and quality of life. The identification of effective treatments for VFD is a key priority relating to life post-stroke. Understanding the natural evolution of scanning compensation over time may have important ramifications for the development of efficacious therapies. The study aims to unravel the natural history of visual scanning behaviour in patients with VFD. The assessment of scanning patterns in the acute to chronic stages of stroke will reveal who does and does not learn to compensate for vision loss.


Eye-tracking glasses are used to delineate eye movements in a cohort of 100 stroke patients immediately after stroke, and additionally at 6 and 12 months post-stroke. The longitudinal study will assess eye movements in static (sitting) and dynamic (walking) conditions. The primary outcome constitutes the change of lateral eye movements from the acute to chronic stages of stroke. Secondary outcomes include changes of lateral eye movements over time as a function of subgroup characteristics, such as side of VFD, stroke location, stroke severity and cognitive functioning.


The longitudinal comparison of patients who do and do not learn compensatory scanning techniques may reveal important prognostic markers of natural recovery. Importantly, it may also help to determine the most effective treatment window for visual rehabilitation

Continue —> Full Text PDF

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[WEB SITE] Vision Rehabilitation PPP – 2013 – American Academy of Ophthalmology – Full Text HTML/PDF


All ophthalmologists are encouraged to provide information about rehabilitation resources for patients who have vision loss. Even early or moderate vision loss causes disability, and it can cause great anxiety and affect visual performance. When available, consider referral for multidisciplinary vision rehabilitation. There is emerging evidence that vision rehabilitation improves visual performance and, hence, quality of life…

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via Vision Rehabilitation PPP – 2013 – American Academy of Ophthalmology.

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