NORA

NEURO-OPTOMETRIC REHABILITATION ASSOCIATION, INTL

PO Box 14934 Irvine, Santa Ana CA 92623-4934

Phone: 1-866 2C-BETTR (866-222-3887)
Web site: WWW.NORA.CC email: noraoptometric@yahoo.com

CLINICAL PEARLS

Spatial Rehabilitation Using

Field Enhancement Prism Systems
Jannie Shapiro, MEd

It is not uncommon for a visual field loss to occur as a result of a CVA or traumatic brain
injury. The course of treatment, particularly for a homonymous hemianopsia, is the use of a
temporary Fresnel expanded field prism placed base-out on the lens of the affected side.
During the neuro-optometric evaluation, the doctor can determine the need for such
treatment and the appropriate placement of the lens. However, in order to ensure success for
the patient, training should be implemented to develop scanning techniques for traveling and
increased field awareness.

An orientation and mobility instructor or therapist can provide the training. Most
importantly, the training should be progressive, bringing the patient from an understanding of
how the prism works to the point where he or she can effectively and safely travel while
wearing the prism system. During the training sessions, the instructor can also determine if
the placement of the Fresnel prism is functional and effective for the patient.

Initially, pre-training issues should be discussed and demonstrated. These issues include
scanning, the blind spot created by the line between the carrier lens and the Fresnel prism
and safety issues (ie-not relying on the prism to give information regarding distance, height
and speed of movement of an object).

Training should then be provided in a static setting with the goal of moving on to a dynamic
one. While the patient is seated, the trainer should demonstrate the displacement effect that
occurs when viewing through the prism. Activities of scanning should be provided to
demonstrate the functional effects of displacement. The patient should also be asked to reach
for objects seen through the prism in order to develop accurate eye-hand coordination.

The next step should involve a demonstration of increased functional field awareness. The
patient is asked to stand in a hallway. The instructor walks past the trainee on his affected
side, asking the patient to indicate when he can see the instructor. The patient should be
looking straight ahead. Next, the patient is asked to look into the prism and repeat the same
activity. A comparison of when the instructor was detected is then made, demonstrating the
effectiveness of the prism for quick object localization.

The next stage of training involves movement. The patient is asked to walk in the hallway
while scanning in and out of the prism. He must try to locate objects in the hallway and
describe them. If the patient is unsteady, a sighted guide (holding on to the elbow of the
trainee) may be used initially. As the patient becomes more comfortable, the instructor can
use increasingly complex environments and situations. The instructor can walk alongside the
patient and then move diagonally in front of him from the affected side to test and improve
reaction time. The patient can be asked to reach out and touch the instructors hand in
different positions as he walks to improve dynamic scanning techniques. Outdoor training
can also be provided, with reminders that the prism should not be used to detect approaching
cars, stairs or curbs.

As the patient becomes more comfortable and efficient in the use of the expanded field
prism, this treatment approach should prove to be successful and long lasting for him. After
this temporary system has been determined to be successful a permanent mounted prism
system can then be prescribed.

This training approach is based on Functional Evaluation and Training Techniques in the
Use of Fresnel Prism for Individuals With Restricted Visual Fields by Duane Geruschat PhD
and Audrey Smith PhD.