What other doctors are saying about the Visual Field Awareness System™

 “A common comment from our patients is that they ‘can actually see again.’  Rekindle has helped a lot of our patients drive again and has even helped some return to their jobs.  When lecturing, I commonly tout the importance of using the system with patients suffering from hemianopic field loss.”

Dr. Rich Windsor

The Eye Associates

Hartford City, Indiana

“People have passed their driver’s evaluations by using the system.  I see driving as a primary reason people invest in it.  It allows people to see more clearly and when used regularly, can improve their vision.”

Dr. Neil Margolis

Arlington Heights, Illinois

“We had a 78-year-old patient with very few cognitive difficulties.  Her main goal was to drive again.  She was fitted with the system and went through a driving training program.  Although she was nervous about taking the driving test, she passed and now drives herself around town.”

Laura Pankow, O.D. PhD.

University of Chicago

Chicago, Illinois

Visual Field Loss (Homonymous Hemianopsia) and “Neglect”

Patients suffering neurological insult frequently have visual field loss.  The visual field loss is oftentimes to the right or left involving anywhere from a small portion to a complete half of one’s vision.  When the visual field loss, because of the neurological cause, is equal in the right and left eyes, this is known as a homonymous hemianopsia.  Sometimes the loss is absolute and this is usually associated with visual “neglect.” When the visual loss is relative verses absolute, the patient can also have visual “neglect,” however usually to a lesser degree.  The visual field loss can also be constricted or within one small area of the visual space.

Isn’t there something that can be done?

One researched and effective treatment for homonymous hemianopsia is the Visual Field Awareness System™ (VFAS), marketed in the United States by Rekindle™, the vision rehabilitation and research arm of Gottlieb Vision Group of Stone Mountain, Georgia.   Daniel D. Gottlieb, O.D., an optometrist and one of the founding members of The Neuro-Optometric Rehabilitation Association International (NORA, Int.) is the inventor and holds the patent on this technology.

The system is based on a circular prism, or prism “button,” mounted within one lens in a pair of eyeglasses. A prism bends light rays, allowing the person to see a part of the visual field that has been cut off by the hemianopia.  The prism is mounted to one side out of the wearer’s direct view when looking forward. For example, if the person has right hemianopia—meaning the right peripheral vision is missing—the prism is mounted on the right side of the right lens of the eyeglasses (see patent diagram).  In some cases of hemianopsia, the prism is mounted nasally with the base of the prism button facing the side of the visual loss.

Picture of Dr. Gottlieb's patent for the VFAS

In cases of visual loss from trauma with constricted visual fields, as is also seen in retinitis pigmentosa and glaucoma; multiple prisms are mounted laterally on each lens.  In the case of inferior field loss from ischemic optic neuropathy, a yoked prism prescription with base downward in the inferior lens is helpful. Yoked prism prescriptions are incorporated into the VFAS as required for posture and to enhance reading potential.  Yoked prism prescriptions with usually a power less than 10 prism diopters will compress the text oftentimes allowing easier reading.

How does it work?

The Visual Field Awareness System works by superimposing what is not seen over what is seen.  Patients are better able to see and perceive a combined, or “gestalt” view of the surroundings. Being able to visually fill in the gaps and understand the missing areas is invaluable in function and safety.

In the case of right hemianopia, when the person glances to the right the prism superimposes images from the blind spot onto the scene viewed by the left eye. Because each eye sees the world from a slightly different angle, this superimposition of images results in momentary double vision.  In the older individual the changing spatial positioning can be confusing, but over time and with training, many people can become accustomed to their prism medical system.

Patient wearing the VFAS system

While looking into the prism the patient must identify which image is real and which is not.  The patient has his/her own way of describing the false image.  Patients will often times describe the false image as being slightly less distinct. The superimposed image can be used as a visual cue; that is, if the prism catches sight of an object of interest, the person can turn his/her head toward it.  At this step, to differentiate the real image from the superimposed image, a patient will use a “two step saccade” to localize an object within the visual field loss, and then move his/her head to alleviate the double vision.  This allows the person to orient with respect to the object. Some people learn to orient themselves to the superimposed image without shifting their gaze away from the prism.  Patients can also learn to use the scene observed through the prism to reach out and grab objects.

What are the potential benefits?

The Visual Field Awareness System can expand a person’s awareness of objects normally outside the limits of peripheral vision.  The immediate benefit to the user of the prism is improved function and safety. Fear of collisions with doorframes, chairs, and other people, frustrates and isolates many people with hemianopia. These people shy away from going to shopping malls and the grocery store, and are petrified of children who come running across in front of them because they inevitably do not see them until they bump into them.

By using the Visual Field Awareness System, patients with hemianopia function more normally and will be less restricted in their daily activities by the vision loss. The result is increased safety and decreased risk of secondary insult and injury.  Training is the essential component to a patient’s successful adaptation to sectoral prism and the Visual Field Awareness System and strategies.

Is recovery possible?

In a study by Gottlieb, Freeman and Williams, 27 of 34 patients fitted with the prism system kept using the Visual Field Awareness System either full-time or part-time over a 2 1/2 year period.  Gottlieb later reported on functional outcome measures and recovery of lost vision in some patients. The prism expanded patients’ peripheral vision an average of 13 degrees. Gottlieb and co-authors in NeuroRehabilitation (1998) describe patients with increased functional outcome measures, increased awareness, and, in some cases, changing neurology with recovery of lost vision. Gottlieb describes the degree of recovery of hemifield impairment and increased threshold sensitivities being greater than reported by any other investigators in the medical literature. The Visual Field Awareness System and treatment strategies enhance functional abilities, emotional well-being, attention, safety, independence, and in some cases a return to independence with safe driving.

At the 11^th International NORA Symposium in April of 2002, Dr. Daniel Gottlieb and Dr. David Cantor, Clinical Neuro-psychologist, presented objective QEEG measures, pre and post Visual Field Awareness System and vision rehabilitation.  Quantitative Electroencephalogram measures document changing brain and changing brain function.  These findings are groundbreaking.

Is return to work possible?

Gottlieb and co-authors in NeuroRehabilitation (1998) describe outcomes including functional independence and return to competitive employment and/or volunteer work following implementation of their neuro-optometric strategies.  The Gottlieb Vision Group rehabilitation team will oftentimes guide the return to work with job analysis, job site evaluation, and recommendations with the work team.

Will vision continue to improve even when completed with the instruction?

The recovery of vision is dynamic and will, in some cases, continue even after a treatment protocol is completed. The trend for this continued dynamic improvement is associated with wearing of the Visual Field Awareness System.

Will vision worsen if the patient discontinue wearing the Visual Field Awareness System™?

The literature has reported a decrease of recovered vision, diminish generalized function, and impaired performance including balance and movement, when a patient stops wearing the Visual Field Awareness System.  Again, wearing the system, even after the treatment protocol, preserves the dynamic increased vision abilities. Not continuing to wear the system can have a negative and deteriorating effect on vision recovery and function.

What are the costs?

 The cost varies depending on the type of prescription (such as bifocals, trifocals), extra features available, such as yoked prism in the overall prescription lenses, and special tinting or coatings for the lenses.  The prism glasses are oftentimes reimbursable through insurance depending on your coverage. Presently, Medicare does not cover the cost of any low vision device.

Another expense is the training required for people to be able to use the prism properly. The patient may need 10-12 training sessions, initially, just to become accustomed to the system. If the patient wants to drive, additional training is required.

The cost of not having this technology far exceeds the monetary cost of the system. The costs of not having the technology include:

·        Functional impairments

·        Disability

·        Vocational impairments

·        Preventable community and federal financial burdens including Medicaid and Medicare

·        Orthopedic, postural and gait disorders

·        Neuro-psychological issues including hallucination and depression

·        Lack of independence

The costs of the technologies and vision rehabilitation strategies are minimal when considering the costs of a potentially permanent visual impairment.  Most important is the loss of a contributing member of a community, lost to family, friends, and an important member of the work force.  The benefits of early and immediate intervention cannot be overestimated, as this is the key to facilitating an optimal functional outcome.

Complex visual loss does not need to be an insurmountable impairment.  Using technology hand in hand with proven rehabilitation strategies, can help to meet the needs and goals of the patient, and the rehabilitation team.

Binocular Sector Prisms and Press-on Prisms – Are these comparable?

Binocular sector prisms are not as effective.  As the Visual Field Awareness System, it’s technologies and it’s strategies.  The effect is temporary and the patient has a subjective impression of improvement but not an actual measured increase in awareness that sustains over time.

Sector prism systems can be made out of press on prisms, but many patients report these prisms cause significant loss of contrast due to poor optical quality, decreased acuity, reflections, and prismatic distortion. These disadvantages are amplified with increasing prism powers. Patients also complain of the appearance and discoloration evident over a short period of time. Those in the research protocol often commented that the press-on prism was a nuisance rather than help. Patients disliked looking into it, which caused avoidance, thereby amplifying the hemi-attentional neglect. (Gottlieb, Freeman, Williams 1992). The Visual Field Awareness System™ is a permanent, optically ground, refractively corrected, optically clear system.

Can the medical system be tinted?

Tinting lenses for contrast enhancement, glare control and photosensitivity, even using photochromatic lenses, is possible. Sometimes tinting can further decrease already reduced contrast and relative visual field desensitivity.

Patient with tinted VFAS

Are there other patients who can benefit?

Anyone with homonymous hemianopia can potentially benefit from the button prism system, even years after the onset of the visual loss. Additional applications include quadrantopsia, constricted visual loss, sector visual loss, and more complex visual loss where only one quadrant of vision may be remaining. This technology has also been used in patients with visual field loss in only one eye from retinal detachments and/or optic nerve disease such as Drusen oftentimes with inferior visual field loss.

Where can I go to read and learn some more?

If you would like to find out more about the prism system, contact Gottlieb Vision Group: 404-296-6000 or toll free: 866-314-2020. Many patients will travel to Atlanta, since Atlanta is just around the corner from anywhere in the world! However, when traveling to Atlanta is not possible, the Gottlieb Vision Group staff can help you locate the closest optometrist or ophthalmologist who can fit you with the Visual Field Awareness System™ and train you on its use.

To read more about Visual Field Loss (Homonymous Hemianopsia) and Visuospatial Neglect click here to review the information prepared by Dr. Daniel D. Gottlieb, and his colleague in Bakersfield California, Dr. Penelope Suter. This was prepared for a NORA, Int. Information Paper entitled Visual Dysfunction Following a Neurological Event. www.nora.cc