Susanne Trauzettel-Klosinski
Centre for Ophthalmology,
University of Tübingen, Germany
Hemianopia: main activity limitations
and participation restrictions
 Orientation disorder
- bumping into objects or persons
- problems with wayfinding
- impaired communication
 Reading disorder
if the field defect involves the centre
 Resulting in
- Reduced participation in the society
- Severe reduction of quality of life!
The hemianopic orientation disorder
General aspects of rehabilitation
Three main aspects need to be considered:
 Optical devices
 Spontaneous adaptive strategies
their knowledge and potential utilization
 Training
Spontaneous adaptive strategies
 Are they helpful?
 Which patients do develop them,
which don`t ?
 Can they be trained?
Spontaneous adaptive strategies
 Eye movements towards the blind side
- small during fixation tasks
- larger during exploration tasks:allow a better
use of the field of gaze
 Attentional shift towards the blind side
 Head turn - unfavorable
Can these spontaneous adaptive
strategies be used for training?
General aspects of training studies
 specifity:
 exclude spontaneous recovery
 exclude placebo effects by using a control group
 reliability:
 assess the potential success by suitable methods
 aim:
 which improvement is clinically relevant?
 can the newly learnt ability be applied to everyday life?
 does the effect persist after training?
Note the difference:
 Visual Field:
seen area during straight viewing direction –
without eye movements
 Field of Gaze:
Seen area WITH eye movements
As it had turned out that
methods to restitute the visual field did not produce
the desired results
and methods to compensate by eye movements
were not yet verified by control groups
We performed the following study:
Comparing explorative saccade and flicker
training in hemianopia: A randomized and
controlled study
Roth T, Sokolov AN, Messias A, Roth P, Weller M, Trauzettel-Klosinski S
Neurology 2009; 72: 324-331
This was the first randomized controlled study
Explorative saccade training EST:
Digit search task
Summarized Results:
Saccadic Training Study
Explorative Saccadic Training EST
 selectively improves saccadic behaviour, natural search and natural
scene exploration
 The new saccadic strategy can be applied to everyday life
 The training effect remained stable after end of training
 Even patients with long-standing hemianopia improved
 Quality of life in social domain improved
Flicker stimulation training FT (control group)
 Did not change visual fields
 Exploration was unchanged
Roth et al, Neurology 2009
Conclusions: Saccadic Training Study
Compensational approach: Explorative Saccadic Training EST
 is specific to improve utilization of the field of gaze
 is evidence-based and recommendable
 The training developed and used in this study is available as software
 Compared to other saccadic training methods, which use mostly
oculomotor training or single target search tasks,
the training of this study has special features:
- multiple target search task (relevant for everyday demands)
- diagnosis specific (hemianopia, quadrantanopia)
- easy to use, also for patients without prior PC experience
- independent training at home
- low costs
Further developments since 2009
Personal Version for Patients
Available as software
To use independently at home with USB-Stick
3 levels of difficulty
Feedback for the patient during the training
Professional Version – additional options
Patient data bank
Several patients trainable simultaneously or successively
Import of external data (from patient`s USB-stick)
Areas of application
Rehab-Units, private practice and at home
Available in 17 languages
Saccadic Training for Hemianopia
Developed at the Low Vision Clinic
Center for Ophthalmology
University of Tuebingen, Germany
Available in 17 languages
– also in Danish and Swedish
Thanks to the colleagues from
all over the world for the
Further information:
Distributed in Scandinavia by Indenova
Reading performance
in hemianopia depends on:
 the side of the field defect (reading direction)
 its distance to the midline (size of reading visual field)
 presence or absence of adaptive strategies,
such as
 eccentric fixation
 predictive saccades
Reading training in hemianopia
 Can adaptive strategies be trained?
 How can eye movement strategies overcome
the sensory deficit?
Approaches to improve reading
in hemianopia
 Support for orientation on the page:
visual and tactile aids
(index finger, ruler or slightly magnifying ruler
with red guide-line)
 Predictive saccades to the beginning of the next line
 Turn text in vertical or diagonal orientation
 Computer training with scrolled text
(Zihl et al 1984, Kerkhoff et al 1992, Spitzyna et al 2007)
The only randomized and controlled reading training study in right
hemianopia reported an improvement of reading speed. (Spitzyna et al
Neurology 2007: 68)
How to measure reading speed?
Standardized assessment
is necessary!
International Reading Speed Texts
Paragraphs of text (approx. 130 words per text)
More accurate than single sentences, size of newspaper print, considering
the everyday-demand
Standardized: Same length, difficulty, content and
linguistic characteristics in the different languages
Set of 10 equvalent texts in each language for repeated
measurements and international studies
Now available in 17 languages
Hahn et al , BJO 2006
Trauzettel-Klosinski S, Dietz K and the IReST Study Group (2012)
IOVS 53:5452-5461
International Reading Speed Texts IReST
The tool for an
evidence-based procedure!
• reproducibility
• comparability
• success documentation
The tool for international multilanguage reading studies!
The 2nd edition with 17 languages
is now available
Further information see and Flyer
Final summary:
Evidence-based training methods for
For reading
 in right hemianopia: scrolled text
 further studies are desirable
For orientation
 Explorative saccadic training

Rehabilitation in TBI Hemianopia