Lytle_ Jody

							PATIENT NAME: Jody Lytle
BIRTHDATE: 11/11/60
FINAL TREATMENT DIAGNOSES and [ICD-9]: Right Homonymous Hemianopsia
[368.46]; Presbyopia [367.40]; Hyperopia [367.0]
DATE OF INITIAL CONSULTATION: February 17, 2010
SERVICE PERFORMED: Low Vision Rehabilitation Evaluation (80-min)
REFFERRING PHYSICIAN NAME and ADDRESS:

Dr. Brad Sutton, O.D.
Indianapolis Eye Care Center
501 Indiana Ave. Ste. 100
Indianapolis, IN 46202

Dr. David Diaz M.D.
LaRue D. Carter Memorial Hospital
2601 Cold Spring Rd.
Indianapolis, IN 46222

Rosemary Armour, COTA
Neurorehabilitation Center
9531 Valparaiso Ct
Indianapolis, IN 46268

HISTORY OF PRESENT ILLNESS:
The patient is a 48 year-old right-handed Caucasian female who has a known right
homonymous hemianopsia related to an arteriovenous malformation diagnosed in 1989.
This low vision evaluation is the patient’s first attempt at treatments for this condition.
Other diagnoses include: Schizophrenia and Bipolar Personality Disorder per Dr. Diaz’s
notes. She is currently independent for ADL’s. She is an inpatient at LaRue Carter
psychiatric hospital and was unsure of her planned discharge date. She had a serious
accident with injuries 2 years ago and has not had her own vehicle since but still drives
short distances regularly.

CHIEF COMPLAINT: “I can’t see on my right side to drive well” “I would like to
return to work” Patient did not fill out a visual functioning questionnaire.

GOALS:
 Driving
 Return to work

PREVIOUS MEDICAL HISTORY:
    Arteriovenous malformation with subsequent surgery (1989)
    Heart Disease with embolizations found in 1993
    Stroke
    Heart Arrhythmia

CURRENT MEDICATIONS:
    SEE ATTACHED MED LIST

SOCIAL HISTORY;
Jody Lytle currently resides at the LaRue D. Carter Memorial Hospital although she
reports that she will soon be released from the hospital and “hopefully moving in with
her father”. She currently still drives an automobile on her own despite feeling that she
needs help in that area. Ms. Lytle was accompanied by a worker from the LaRue D.
Carter Memorial Hospital at today’s visit.
SIGNIFICANT FINDINGS:
 Best corrected vision right eye: 20/20 with +0.25 DS and left eye: 20/20 with +0.75 DS, 20/20 both eyes
   together.
 Low normal binocular contrast sensitivity, 1.68, tested with Mars-Perceptrix card.
 1.6M continuous text acuity read at a fluency of 120 words-per-minute without any reading glasses.
 Continuous text acuity and fluency improves to 0.8M and 120 wpm using a +2.25 add.
 Patient demonstrates reasonable visual search strageties in the hemianopic field only requiring 2-3 steps to
   locate a peripheral target on the right side.
 Impaired rightward ocular pursuits, with loss of fixation
 Rightward saccadic hypometria consistent with CVA locus, mild.
 Confrontations show complete right homonymous hemianopsia with macular splitting. There may be some
   sparring of motion in the inferior quadrant.
 Computerized visual Field consistent with a right homonymous hemianopsia on computerized 30-2SS visual
   field test.
 Visual field expanded 20 degrees using EP Horizontal expansion prism. Well tolerated by patient.

RECOMMENDATIONS:
 Start vision rehabilitation after discharge from LaRue Carter Including:
       o 1-week trial with two different expansion prism designs; EP horizontal and VFAS.
                  Primary goal of visual aids should be to improve mobility and reduce risk of falls
                  Improving safety behind the wheel may be a secondary benefit if the patient is already safe to
                       drive.
       o Concurrent driver rehabilitation with the Rehabilitation Hospital of Indiana (RHI), order written and
             given to patient today. OT to assess performance behind the wheel without visual aids and then with
             each type and provide recommendations.
                  Obtain clearance for on-road assessment from Dr. Diaz or RHI psychologist (Backhaus,
                       Hufford, or Trexler) considering the impact of her psychiatric conditions on driving.
                  Also eval for adaptive equipment in the vehicle
                  Provide recommendations on driving restrictions or to discontinue
       o Hemianopic rehab protocol with OT vision services at RHI, order written and given to patient today.
                  Awareness of visual loss
                  Eccentric viewing
                  VST (visual scanning) strategies with anchoring
                  Using line guides and word isolation
                       Applying techniques for ADLs, O&M
 Reinforce Patient education on driving risk and recommendation not to drive until driver assessment and
   rehabilitation is completed.
 Continue with current glasses. A new bifocal prescription is needed, however we will hold on ordering for
   now.
 Patient to enroll in State Vocational Rehabilitation program ASAP upon discharge from LaRue Carter.
 Continue ocular health care with Dr. Sutton
 Continue Psychiatric care as directed by Dr. Diaz.

SHORT-TERM PLAN WITH TIMEFRAMES:
   1.  1 – 2 month follow-up
          a. Fit for trial expansion prism.
          b. Review goals and recommendations
          c. Discuss Voc Rehab again if patient not enrolled
          d. Discuss occupational therapy referral again as needed.
   2.  Patient to have on-road assessment with trial prism during this period
   3.  Progress evaluation 1-2 weeks after prism fitting.
          a. Evaluate sector prism and adaptation
          b. Order EP prism
   4.  Dispense visual aids.
              a.   Evaluate sector prism
              b.   Train sector prism use with EP training animation and stimulus saccade task, and saccadic fixator.

EXPANDED ASSESSMENT

Jody Lytle, accompanied by a worker from LaRue Carter, appeared non-distressed in her initial low vision
evaluation. She reports that she will soon be released from the hospital and “hopefully moving in with her father”.
She has a long-standing right homonymous hemianopsia. To summarize, she has an absolute loss of the entire right
side of her vision in each eye that shifts with the position of the eye. For example if she looks straight the blind area
starts at the middle of the right eye and over; if she looks left the blindspot moves to a position equivalent to the
degree of the eye turn obscuring objects directly in front of her. Conversely a rightward eye-movement moves the
blindspot out of the way providing a full visual field. A therapy technique called eccentric viewing training takes
advantage of this characteristic by teaching the patient to momentarily hold the eyes in the rightward position to
obtain a panoramic view of their surroundings. This combined with teaching compensatory scanning techniques
encompasses the therapeutic interventions for hemianopsia. In examination today Jody exhibited reasonably good
compensatory skills showing good awareness of the presence and location of the blindspot, was able to locate the
edge of it with her hand without prompting, and was aware that there is vision missing in each eye. She was poorly
aware of how to eccentrically view, choosing to turn her head rather than the eyes, indicating this as a technique she
uses when driving. Patients with hemianopsia will commonly use this ineffective technique in an attempt
compensate and can be easily retrained. This is an area our therapist can focus on to improve her function for daily
activities, and if appropriate, driving. We are certain that her vision loss contributes to increased driving risk,
however hemianopsia has been show NOT to be a total contraindication to driving, with some people compensating
without any problems. We therefore typically require an on-road assessment for these patients before making a
recommendation unless they are clearly impaired in other ways. I am not certain of the impact of her psychiatric
conditions on driving and would appreciate input from Dr. Diaz or one of the psychologists at RHI prior to
beginning the driver rehabilitation process. Hemianopsia can also be treated with an expansion prism, which is a
high powered prism that is drill mounted in a portion of the glasses lens. Designs vary, but she may obtain as much
as 25 degrees of expansion and responded well to a trial in office today. The lens is meant to improve mobility and
object detection, and is used by some patients during driving only after it is determined to be helpful. We have had
success in funding this visual aid through the Vocational Rehabilitation program and for patients on Medicaid. I’ll
look forward to guiding Ms. Lytle through the entire vision rehab process when or if it becomes appropriate.

Results of the evaluation were reviewed with Jody Lytle and the treatment plan was developed with her input and
approval. Drew Hoffman, Optometry Student assisted in the examination. I thank Dr. Sutton for the kind and
important referral. I can be contacted at kehousto@indiana.edu or I am available for phone conference MWF at
317-321-1470 or R at 317-278-5975.




Kevin E. Houston, O.D., F.A.A.O                                                     Date