A Stroke Of Bad Luck For Irene

Strokes are like hurricanes in the brain.  There is no such thing as a good one, only the extent of damage it causes.  Irene came through our region recently, both in the from of Hurricane Irene, and in the form of a 60 year-old patient by the same first name.  Until the end of July, our patient Irene was sharp as a tack, running her own business that centered on headhunting computer specialists.  She’d been feeling kind of run down this past year or two, working long and intense hours, but she continued to push herself.  She began to note that her vision wasn’t quite right, and her primary care optometric physician (PCOD) tweaked her prescription a couple of times.  In retrospect her perception was off a bit, but nothing alarming at the time.  Reading, which was one of her joys, had become more tedious.

Her PCOD sent her to consult with a neuro-ophthalmologist who, in Irene’s words, was a real jerk.  “He seemed more interested in billing than in listening to me”, she noted.  He said he might be able to do some eye muscle surgery, but wasn’t sure how much it would help her symptoms.  The PCOD treated Irene for dry eyes, proceeding from Optive to Genteal to Lotemax to Restasis.  Irene said that the “dry eye cocktail” made her eyes feel less dry, but did nothing for her perception of things looking “off kilter”, or for her fatigue when reading.

And then BOOM!!!  The stroke hit at the end of July, and Irene headed to the hospital.

Like her namesake hurricane, we say “it could have been worse”.  But what Irene was left with was frustration.  She realized she could no longer drive if things remained this way.  She lost almost half of her peripheral vision, experiencing a near total left homonymous hemianopia. As you can see from her fields here, there was a little sparing, or perhaps in the 6 weeks since her stroke a little restoration, of her inferior  quadrant just a little bit to the left of her visual midline, which I highlighted in yellow.

The peripheral vision loss on the left side explained not only why she couldn’t drive, but why she would be surprised by things on her left side.  Just the other day she was walking down the aisle at CVS and bumped into someone.  Not in the sense of seeing them unexpectedly, but in not seeing them at all!  Her PCOD referred her to me specifically, as he told her neurologist, to see if prisms would be of any benefit to Irene in expanding her visual field awareness.

But wait.  There was another fly in the ointment.  Irene has learned to position material to her right side in order to read better, yet reading was more difficult than what she had anticipated.  Theoretically since she was reading left to right, Irene’s problem should have been in going from the end of the line to the beginning of the next line, since that required tracking or scanning into her field loss.  Binocular testing unmasked the cause of her fatigue and frustration.  She had a significant vertical imbalance.  It was as if her see-saw had been tipped low on one side and high on the other side.  We had Irene map out her binocular visual space projection through stereoscopic pencil/paper tracing.  This is what she drew:

Irene’s visual space judgment was not only skewed vertically; it was off horizontally as well.  A profile of her binocular projection on the Keystone Visual Skills Test shows that she projects high exophoria at disatance and near with exo diplopia.  In other words, Irene expends significant effort to keep her visual world clear, binocular, and stable.  To what extent does Irene’s visual field loss relate to her vertical and horizontal imbalance and moderate cyclotorsion?  Alot, as it turns out.  These issues and their treatment are discussed in a book on I’ve mentioned before on vision rehab following brain injury.  But I recently stumbled onto an elegant description by Mark Wagner that I’d like to paraphrase as it relates to Irene:

When most people think of space, they think of physical space. However, visual space concerns space as consciously experienced, and it is studied through subjective measures, such as asking people to use numbers to estimate perceived distances, areas, angles, or volumes. In certain circumstances there is a mismatch between perception and physical reality.  There are many factors that influence the perception of space including the meaning assigned to geometric concepts like distance, the judgment methods used to report the experience, the presence or absence of cues to depth, and the orientation of a stimulus with respect to point of view.  No single geometry describes visual space; the geometry of visual space depends upon the stimulus conditions and mental shifts in the subjective meaning of size and distance.

In Irene’s case prisms didn’t initially influence her visual field awareness, but her evaluation is just the starting point of a process.  Irene related that her PALs (Progressive Addition Lenses) were not easy to adapt to in the first place, and we know that even pre-adapted PAL lens wearers can have visual-vestibular problems with these lenses after ABI/Stroke.  We’ll work closely with her PCOD on this, and we’ll monitor changes in lens power, form, and indications for yoked prism.  Irene is a determined, independent, goal-oriented, and  successful woman.  She’s excited about beginning VT next Monday, and we can’t wait to see her recapture a stronger semblance of her former visual self.

– Leonard J. Press, O.D., FCOVD, FAAO

4 thoughts on “A Stroke Of Bad Luck For Irene

  1. Dr. Press, I look forward to learning more about Irene’s case. I find your case studies interesting, and very much appreciate your book reviews/comments.

    It continues to astound me the issues patients needlessly put up with, things that impact heavily upon their lives at work, at home, emotionally, physically through activity and general self-care – and even in intimacy – and needlessly so. Truly it’s astounding, and more so when considering the long line of ‘specialists’ many patients see haven’t the foggiest notion of how to deal with the more significant elements of patient care: Behaviour. Medical issues are generally addressable, or not. This is, however, not the end of care but the beginning.

    Vision is so integral to our motor and sensory beings, vision care professionals cannot simply assume that if the eye is healthy, all is well. There seems to be a prevalent view (in western medicine, psychology, and teaching faculties) that the visual system, in spite of its tremendous importance and complexity, is absolutely uniform in function between all individuals. We accept that one child skates better than another, but somehow, miraculously ALL children are equally advantaged visually. Blind or not blind. Medical practitioners generally do not look further than the machine, for the most part. You don’t have to dig too deep to find a mechanistic view of the patient in health care that proves more of a hindrance than accelerator of care. We, on the other hand, turn patients into people, and eliminate the ongoing burden of healthcare. Not everyone can say that.


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