Management of central field lossEccentric Viewing training – Part 1

Content prepared & presented by Dr Meri Vukicevic

Additional attribution/acknowledgement:A significant proportion of the content of this presentation was

initially developed by A/Prof Kerry Fitzmaurice and has been added to/modified for the purposes of this presentation here.

Central field loss

Eye Research Australia (Clear Insight) Economic Impact and Cost of Low Vision in Australia (2004)

Image from: National Eye Institute, National Institutes of Health [Public domain], via Wikimedia Commons

Indications for eccentric viewing training

• Absolute bilateral central scotoma• Ability to comprehend and remember simple

instructions

• Can be modified…..

How does it work?

Scheiman, Scheiman & Whittaker (2007) Low Vision Rehabilitation. Slack Inc. Pg 146

Terminology

Preferred Retinal Locus (PRL)

Retinal area that behaves as a pseudo fovea and is

adopted by the patient in order to see chosen objects

Trained Retinal Locus (TRL)

Eccentric retinal area that the clinician has determined to

be the best position in which to train eccentric viewing as it is the closest position to

the fovea

Which PRL/TRL location?

• Visual sensitivity is greatest at the fovea/macula

• Therefore, optimum retinal locus for EV Tx would be as close to the fovel as possible

Which PRL/TRL location?

• Choose a position as close as possible to the damaged fovea

• Do not ignore horizontal positions - acuity outweighs convenience

• Use the eye with the most viable position - binocularity is not an issue

• To stimulate a given retinal locus turn the eyes in that direction ie to stimulate right temporal retina turn the eyes to the right

Scheiman, Scheiman & Whittaker (2007) Low Vision Rehabilitation.

Slack Inc. Pg 146

Baseline assessments

• Near & distance vision• Other reading materials• Photographs• Performance of specific tasks

• Re-assess progressively throughout training

FINDING THE OPTIMAL TRL

Option 1: Bjerrum tangent screen

Option 2: EV Home Resource kit

Eccentric Viewing Home Resource kit developed by Fitzmaurice, K

Option 3: EccVUE

EccVUE – module 1Fitzmaurice, K., Kinnear, J., & Chen, Y. (1993). A Computer Generated Method of Training Eccentric Viewing. Australian Orthoptic Journal, 29, 13-17.Image courtesy of Kerry Fitzmaurice.

Option 4

Braun Wanduhr ABW 41 (1981) clock face adapted from Wikimedia Commons.Author: Phrontis

Pre-training considerations

• Be realistic when offering training– A good indicator of potential success is the

viability of the peripheral retina

– Remind your patient that eccentric vision will

never be as clear as foveal vision

During training

• Patient should wear reading glasses if presbyopic– full readers are better than bifocal segments

• Use baseline assessments such as print size as

indicators of progress

• A simple functional assessment can be a good

progress meter

• Give constant feedback, remember the patient has

learnt not to trust their vision

Management of central field lossEccentric Viewing training – Part 2

Content prepared by Dr Meri Vukicevic

Step by step

• Locate most viable retinal point (TRL)• Make patient aware of the potential acuity of

this point• Teach patient distance and direction of re-

fixation movement• Provide adequate repetitive practice• Teach application to a variety of circumstances• Teach reading skills if required

Step 1: Scotoma awareness

Step 2: Refixation

Images courtesy of Kerry Fitzmaurice.

EV home resource kitEccVUE module

Step 2: Refixation

Step 3: Practice

Images courtesy of Kerry Fitzmaurice.

Step 4: Wider application

Step 5: Reading

• Some patients may need to gain advanced reading skills

to remain competitive in the workforce or for study

• Build up from single words to well spaced words to

normal text

• Teach line changing techniques

• Introduce line guides

• Introduce reading boards

Step 5: Reading

Images courtesy of Kerry Fitzmaurice.

Step 5: Reading

Images courtesy of Kerry Fitzmaurice.

Step 5: Reading

Conventional reading:

Acceptance and tolerance of others can be like a tonic to

the whole system. A friendly attitude and compassion

Acceptance and tolerance of others can be like a tonic to

the whole system. A friendly attitude and compassion

Reader with vision impairment:

Step 6: Relaxation

• Eccentric viewing takes a lot of concentration especially at the beginning.

• Don’t forget to give your patients a break!– Stop for a chat– Look out a window– Stand up & walk about

Plateau

Vukicevic M & Fitzmaurice K. The Effect of Eccentric Viewing on the Visual Function of Persons with Age-related Macular Degeneration. 2002. Australian Orthoptic Journal. 36:8-11

When to stop?

• When the patient is able to recognise the current print size

with relative ease but can not see anything smaller

• When the patient can just recognise a print size but can not

read it

– Enlarge it by one print size and stop

• When the patient is able to do the tasks you agreed to during

initial planning

– Eg: recognising faces, watching TV, looking at photos, reading

newspaper headlines

References• Vukicevic M, Le A & Baglin J. 2012. A simplified method of identifying the Trained

Retinal Locus for the purpose of eccentric viewing training. Journal of Vision Impairment and Blindness. Vol 106 (9) 555-561.

• Vukicevic M & Fitzmaurice K. 2009. Eccentric viewing training in the home environment: can it improve the performance of dynamic self-care activities of daily living? Journal of Vision Impairment and Blindness. Vol 103(5): 277-290.

• Vukicevic M & Fitzmaurice K. 2008. Vision rehabilitation and the development of eccentric viewing training: a historical overview. Australian Orthoptic Journal. Vol 40(1): 13-18.

• Vukicevic M & Fitzmaurice K. 2005. Rehabilitation Strategies Used to Ameliorate the Impact of Centre Field Loss. Visual Impairment Research. Vol 7: Issue 2-3: 79-84.

• Vukicevic M & Fitzmaurice K. The Effect of Eccentric Viewing on the Visual Function of Persons with Age-related Macular Degeneration. 2002. Australian Orthoptic Journal. 36:8-11