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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 4  |  Page : 1186-1194

Eccentric viewing training for low-vision rehabilitation in patients with central scotoma


1 Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Memorial Institute of Ophthalmology, Giza, Egypt

Date of Submission04-Apr-2020
Date of Decision16-May-2020
Date of Acceptance31-May-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Esraa S Elghoubashy
Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_116_20

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  Abstract 


Objective
The aim was to evaluate the value of subjective eccentric viewing (EV) training in vision rehabilitation in patients with central scotoma.
Background
EV, also known as eccentric fixation, involves identifying a functioning area of the retina that has reasonable sensitivity, and is as close to the fovea as possible, and to learn to use it effectively, which is known as preferred retinal locus.
Materials and Methods
The direction of EV was monitored in 33 low-vision patients with bilateral central scotomas, the preferred retinal locus was identified, and the preserved visual field was found. The patients were divided randomly into two groups regarding their use of optical low-vision devices with EV training. After 2 months of training, changes in near and far best-corrected visual acuity (BCVA) and reading speed were evaluated.
Results
After 2 months of EV training, near BCVA and mean reading speed significantly improved. Regarding the use of low-vision devices, the group that used low-vision devices with EV training showed significant improvement in the near and far BCVA than the group that did not use low-vision device.
Conclusion
EV training can be used as a very effective method for low-vision rehabilitation in patients presented with central scotomas, and it can give very good results using simple and inexpensive equipment.

Keywords: central scotoma, eccentric viewing, low-vision rehabilitation, preferred retinal locus, reading speed


How to cite this article:
Zaky AG, El Bayoumi B, Elghoubashy ES, Sarhan AE, Zaky MA. Eccentric viewing training for low-vision rehabilitation in patients with central scotoma. Menoufia Med J 2020;33:1186-94

How to cite this URL:
Zaky AG, El Bayoumi B, Elghoubashy ES, Sarhan AE, Zaky MA. Eccentric viewing training for low-vision rehabilitation in patients with central scotoma. Menoufia Med J [serial online] 2020 [cited 2021 Apr 19];33:1186-94. Available from: http://www.mmj.eg.net/text.asp?2020/33/4/1186/304477




  Introduction Top


Macular diseases usually cause what is known as central vision loss (CVL). CVL impairs greatly tasks of daily living such as driving, face recognition, object recognition, and reading[1]. For normal patients with a functioning fovea, visual tasks are done by directing the eye such that the image of the visual target of regard is placed within the central foveal area[2]. In contrast, in patients with a central scotoma from any macular disease involving all of the fovea, visual tasks are performed by directing the eye such that the image of the target of regard is placed within an area of the retina that is functioning known as the preferred retinal locus (PRL)[3],[4].

In patients with bilateral central vision impairment, restoration of vision by residual vision training can be a valuable resource that can help them to use the rest of their vision by eccentric viewing (EV)[5].

EV, also known as eccentric fixation, involves identifying an area of the retina that has reasonable sensitivity, and is as close to the fovea as possible in order to maximize details, and learn to use it effectively, which is known as PRL[6].

Many portions of peripheral retina may be suitable for EV, dependent on task demands and the visual properties of the objects being viewed[7].

EV is usually established at an early age in patients with a congenital macular lesion; in contrast, in elderly patients. EV is obtained spontaneously rarely and usually needs a lot of training[8],[9].

**Steady eye strategy (SES) is a technique that specifically helps with reading. SES requires the patient to break the saccadic reflex by keeping their gaze still, and scrolling the text right to left, through their functional area of vision. As the text is moved in SES, the eye can be trained so that the letters fall on the predetermined PRL. Magnification may improve the ability to see the letters, but the patient may still not to be able to read successfully as there are now fewer letters on the PRL at any one time[10].

Many low-vision aids can be used for magnification, which may be optical and nonoptical devices.

Optical devices may be for near or for distant vision. Near devices are designed for magnifying close objects and print such as magnifying glasses, magnifiers that may stand or be hand-held, and telescopes for near. Distance devices are for magnifying things in the distance (from about 3 m to far away) such as telescopes for far[11].

Nonoptical low-vision aids are products built to facilitate self-sufficient living. They alter the understanding of the world by being larger, brighter, and blacker, or by being coloring and contrasting. Thus, the purpose of a nonoptical system is to increase retinal image visibility and maximize the use of magnifiers such as reading lamp; reading stand; writing guide; reading guide; signature guide; bold line papers; black ink; bold tip pens; soft lead pencil 2B, 4B, and 6B; Needle threader; and Notex[11].

There are several teaching methods for EV, the newest of being scanning laser ophthalmoscope (SLO) and microperimeter; they have the advantage that the retinal image is rendered clear, and thus the scotoma limits are seen, and the PRL can be accurately calculated. Microperimeters are very expensive and often not available for vision rehabilitation, especially in developing countries. However, we agree that microperimetry is not necessary for learning to use EV effectively[12],[13].

Many EV training methods such as prismatic scanning or relocation, strips and rotors with letters or numbers of various sizes, and advanced training sheets have been used[14].

However, EV training requires the presence of bilateral absolute central scotoma and the ability of the patient to comprehend and remember simple instructions[9].

In this study, we intended to evaluate the value of subjective EV training in vision rehabilitation in patients with central scotoma.


  Materials and Methods Top


This is a prospective cohort study done on 33 low-vision patients (16 males, 17 females) recruited from the low-vision clinic in Menoufia university hospitals from April 2018 to October 2019, with their age ranging from 8 to 75 years. A total of 30 patients had bilateral central scotoma with one dominant eye, and three patients had unilateral central scotoma in the seeing eye of a single eyed patient.

A written informed consent was obtained from all patients or their guardians. The study was approved by the Ethics Committee of Human Rights, Faculty of Medicine, Menoufia University. All procedures were performed under the tenets of the Helsinki Declaration.

The inclusion criteria for the patients included in this study are as follows: all the patients should have maculopathy that is stable and nonprogressive for at least 6 months before the training and the central scotoma ranges from 10 to 20° from the point of fixation as seen in the visual field of the patient and all the patients should be able to read to able to practice EV training during reading. The exclusion criteria are as follows: patients with ocular diseases other than maculopathy that may affect the visual function, for example, significant media opacity as cataract or corneal opacity, and retinal disorders affecting peripheral and central retina, for example, advanced retinitis pigmentosa. Moreover, central causes of visual impairment, for example, head injury, were excluded from the study. On discontinuation of EV training, during the training period (2 months), the patient was excluded from the study.

All the patients were subjected to complete history taking, including personal history, ocular history, and history of systemic diseases or medications.

All the patients were subjected to full ophthalmological examination including best-corrected visual acuity (BCVA) for distance which was checked at 3 m distance, from Lea translucent symbol distance visual acuity chart '2000,' and BCVA for near at 25 cm distance from Lea symbols near visual acuity chart. Then ophthalmological examination was done, and relevant investigation was performed to reach the proper diagnosis, including slit lamp examination of both eyes to examine the anterior segment of the eye for the presence of any ocular disorder as cataract, intraocular pressure measurement using applanation tonometer to exclude glaucoma, and fundus examination to determine the cause of maculopathy and to exclude the presence of any of the exclusion criteria using direct or indirect ophthalmoscope. Investigations like fundus fluorescein angiography and ocular tomography were done when required. The eye that was used in training was usually the dominant eye of the patient.

For each patient, the visual field was tested using the OCTOPUS 101 visual field analyzer to test the PRL's position, sensitivity, and stability of fixation. Low-vision programme (LVC) was used to test the magnitude of the central scotoma and the location of the best PRL (the nearest macula region with the highest visual sensitivity). A white V test light stimulus with maximum light stimulus intensity of 1910 cd/m2 moved at a speed of 4 degree/s was used in this programme[15].

Reading speed was calculated by asking the patient to read for one minute from the Come closer–reading (Arabic and English) visual acuity test at 25 cm under standard room lighting and counting the number of words read per minute (wpm). We practiced the training with very simple sentences to be easy for every one even with basic literacy skills[16]. The objective position of a patient's PRL was assessed with a direct ophthalmoscope by making the patient identify and fixate on a target transmitted via the direct ophthalmoscope fixation aperture[17].

The procedure used to assess the direction of EV, using the patient's best eye, involved the patient sitting in order to best retinal area test with a sign in the center to be at the level of the eye, and the distance can be modified according to the degree of visual acuity of each patient. The patient is then told not to look directly at the sign in the middle but was asked to look around it at 12 o'clock, 3 o'clock, 6 o'clock, and 9 o'clock positions. The patient is asked to compare the ability to see the sign in the four directions of gaze. If the symbol is more visible in one or more positions, then the areas in between should be tested. For example, if the patient is more aware of the symbol when looking at 12 o'clock and 3 o'clock positions, the vision should be tested again at 1 o'clock and 2 o' clock positions[18].

After the best direction of EV giving the best visual acuity for both near and far vision and the location of the PRL were identified, then the patients were divided randomly into two groups:

  1. Group 1: the patients were trained to use the best direction of EV with the appropriate optical low-vision device with the suitable magnification for every patient for training with one hour weekly session. The patient and their guardians were educated and trained to use EV with low-vision devices at home for reading at the focal length of the devices, such as magnifying glasses, magnifiers that may stand or be hand-held, and telescopes for near and while viewing distance target at about 2 m by telescopes for at least 15 min per day for each distance
  2. Group 2: the patients were trained for using the best direction of EV with nonoptical low-vision devices (large print size) for reading in a weekly session lasting about one hour and home training for 15 min daily session for each far and near vision.


Then, they were all encouraged to use EV in their daily life in recognizing faces, reading newspapers, watching TV, etc.

Patients were educated to adopt eccentric fixation[19] and after 2 months of training sessions and home training, the effect of EV training was evaluated using BCVA for near and distance, and the reading speed for the two groups (group 1 and group 2) was calculated.

Data were collected and entered to the computer using Statistical Package for the Social Sciences program for statistical analysis (version 20; SPSS Inc., Chicago, Illinois, USA). Data were entered as numerical or categorical, as appropriate. Quantitative data were shown as mean and SD, and Qualitative data were expressed as frequency and percentage.

Analytical statistics was done using χ2-test, Fisher exact test, and Paired t test, and P value was considered statistically significant when it was less than 0.05.


  Results Top


This study included 33 patients, comprising 16 were males (48.5%) and 17 were females (51.5%). Age ranged from 8 to 75 years. The mean age was 41.7 ± 26.2. Positive consanguinity was reported in 13 (39.4%) patients, and 20 (60.6%) patients reported negative consanguinity. The right eye was used in the training in 18 (54.5%) patients and the left eye was used in 15 (45.5%) patients. The dominant eye was used in EV training in 30 (90.9%) patients, and the only eye of single eyed patients was used in EV training in three (9.1%) patients [Table 1].
Table 1: Demographic and clinical data of patients

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The distribution of the diseases was nine ARMD (27.3%), nine Stargardt disease (27.3%), five myopic macular degeneration (15.2%), three cone dystrophy (9.1%), three fundus flavimaculatus (9.1%), two optic neuritis (6.1%), one retinopathy of prematurity (3%), and one toxoplasmosis scar (3%) [Table 1].

In all the study cases, after 2 months of EV training, near BCVA and mean reading speed significantly improved (paired t test, P < 0.001); however, far BCVA did not significantly improve (0.1 logMAR on average) [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9].
Figure 1: Colored fundus photography of right eye showing the site of the preferred retinal locus by the direct ophthalmoscope.

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Figure 2: Octopus visual field by low-vision programme of right eye showing the site of preserved visual field.

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Figure 3: The best direction of eccentric viewing by the best retinal area test test.

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Figure 4: Colored fundus photography of right eye showing the site of the preferred retinal locus by the direct ophthalmoscope.

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Figure 5: Octopus visual field by low-vision programme of right eye showing the site of preserved visual field.

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Figure 6: The best direction of eccentric viewing by the best retinal area test test.

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Figure 7: Colored fundus photography of right eye showing the site of the preferred retinal locus by the direct ophthalmoscope.

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Figure 8: Octopus visual field by low-vision programme of right eye showing the site of preserved visual field.

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Figure 9: The best direction of eccentric viewing by the best retinal area test test

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The mean near BCVA improved from 0.97 ± 0.19 to 0.63 ± 0.26 (P < 0.001), and the mean reading speed improved from 26.48 ± 9.31 to 53.82 ± 10.81 (P < 0.001) [Table 2].
Table 2: Changes in visual characteristics after 2 months of eccentric viewing training in all the study cases

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The patients in this study were divided into two groups regarding their usage of low-vision devices with EV training for 2 months:

  1. Group 1 included patients who were trained for using the best direction of EV with the appropriate optical low-vision device with the suitable magnification for near and far vision for every patient (17 patients) (51.5%)
  2. Group 2 included patients who were trained for using the best direction of EV with nonoptical low-vision devices (large print size) for reading and EV only for far vision (16 patients) (48.5%) [Table 3].
Table 3: Comparison between near BCVA and Far BCVA in the group that used optical low-vision devices (group 1) and the group that did not use optical low-vision devices (group 2) after eccentric viewing training

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The group that used low-vision devices with EV training (group 1) showed significant improvement in the near BCVA (0.41 ± 0.17) than the group that did not use low-vision device (group 2) (0.78 ± 0.28). Moreover the group that used low-vision devices with EV training (group 1) showed significant improvement in the far BCVA (0.75 ± 0.17) than the group that did not use low-vision device (1.02 ± 0.28) (group 2) [Table 3].

After analysis of the direction of EV, PRL location by the direct ophthalmoscope, and the visual field in every patient as seen in the attached figures of three cases from the study, we noticed that there was agreement between the direction of EV, PRL location by the direct ophthalmoscope, and the visual field in two-thirds of the patients (22 patients) (66.7%) (agreement group), and there was disagreement between the direction of EV, PRL location by the direct ophthalmoscope, and the visual field in one-third of the patients (11 patients) (33.3%) [Table 1].

In the agreement group (22 patients), the majority of patients present their PRL in the nasal, superior, and superonasal directions as follows: five (22.7%), four (18.2%), and four (18.2%), respectively, whereas three (13.6%) patients represent their PRL in the temporal direction, two (9.1%) patients showed their PRL in the inferior direction, two (9.1%) patients showed their PRL in the superotemporal direction, one (4.5%) patient showed his PRL in the inferonasal direction, and one (4.5%) patient showed his PRL in the inferotemporal direction [Table 4].
Table 4: Distributions of preferred retinal loci in the group that showed agreement between eccentric viewing, preferred retinal locus, and visual field

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There was no statistically significant difference in the initial far BCVA (logMAR) between the agreement (1.01 ± 0.25) and the disagreement group (1 ± 0.27), but there was significant difference between the initial near BCVA (logMAR) and reading speed (words/minute) between the agreement and the disagreement groups [Table 5].
Table 5: Comparison of basic visual characteristics between the agreement and disagreement groups

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There was a statistical significant difference in the near BCVA and reading speed after training between the agreement and disagreement groups, but there was no statistical significant difference between the two groups in far BCVA [Table 5].

In the agreement group, there was significant improvement in the near BCVA from 0.93 ± 0.14 before EV training to 0.52 ± 0.18 at the end of EV training, and also there was significant improvement in the reading speed after EV training (59.09 ± 7.89) than before (29.55 ± 8.06). Moreover, in the disagreement group, there was significant improvement in the near BCVA from 1.06 ± 0.25 before EV training to 0.85 ± 0.27 at the end of EV training, and also there was significant improvement in the reading speed after EV training (43.27 ± 7.75) than before (20.36 ± 8.91). However, there was no significant improvement in the far BCVA in both the agreement and disagreement groups before and after EV training [Table 5].


  Discussion Top


Patients with central scotoma use relatively healthy peripheral areas of retina to view objects[20]. However, this viewing technique may appear unnatural, and with time, nearly all individuals with CVL will select a 'PRL' for EV[21],[22].

However, the factors influencing the production of a PRL at a particular location relative to the scotoma and their characteristics are still not understood[23],[24]. Many studies have also shown that the location of PRLs will vary depending on the type of macular disease present, the target size, the background luminance level, and the functional task[2],[9],[10],[23],[25],[26].

In the present study, PRLs were preferentially located in the nasal, superior, and superonasal areas as follows: 22.7, 18.2, and 18.2% in relation to the fovea respectively, in the agreement group (group A). In contrast, Jae Hoon Jeong and Nam Ju Moon in 2011 reported that PRLs were preferentially located in the temporal (20%) and superotemporal (20%) retina in relation to the fovea in the accordance group in their study[17].

We found that after 2 months (8 weeks) of EV training, near BCVA significantly improved (paired t test, P < 0.001). The mean near BCVA improved from 0.97 ± 0.19 to 0.63 ± 0.26 logMAR. In contrast, Jae Hoon Jeong and Nam Ju Moon found that after 2 weeks of EV training there was little to no improvement in near BCVA, and this may be owing to their short duration of training[17].

In contrast, in 2013, Verdina et al.[24] demonstrated EV training using a microperimeter and audible feedback that encourage the use of a trained retinal locus, which caused a significant improvement in near VA from 0.67 ± 0.18 to 0.56 ± 0.16 logMAR in 12 patients with Stargardt's disease after 10 weeks of follow-up.

Palmer et al.[13] and Vukicevic and Fitzmaurice[27] reported a significant improvement (P < 0.001) in the near VA in all participants in the EV group[13],[27].

The evaluation of reading speed has been suggested to provide a more useful indicator of visual output in individuals with CVL than the evaluation of near VA alone, as reading is a more challenging visual function than finding few optotypes on a visual acuity chart[2],[26].

In this study, we found that after 2 months (8 weeks) of EV training, the mean reading speed significantly improved (paired t test, P < 0.001) from 26.48 ± 9.31 to 53.82 ± 10.81 wpm after EV training, which was in agreement with Palmer et al.[13] who had data from 300 patients who practiced EV training and analyzed their data and found that the starting mean reading speed was 48wpm and this improved to 71.9 wpm, and this showed significant improvement[13].

Moreover, Kasten et al.[12] found a significant increase (P < 0.05) in mean reading speed after training from 57.5 ± 33.0 to 77.3 ± 52.0 wpm after training[12].

Seiple et al.[28] found that the increase in reading speed was statistically highly significant, and also Jae Hoon Jeong and Nam Ju Moon[17] studied the effect of EV training in 30 patients with bilateral central scotoma owing to various causes, and they found that there was significant improvement in the reading speed (P < 0.001).

So, as we see there is agreement that EV training has a very effective role in improving the reading speed and hence the reading ability of the patient. In contrast, in 2011, Seiple et al.[29] found that there was an average decrease of 8.4 ± 7.2 wpm in the reading speed for the EV training group in their research. We also found that high starting reading speeds resulted in high finishing reading speeds. This is not surprising as these learners probably had a better visual acuity and smaller central scotoma.

However, in this study, we did not find significant improvement in far BCVA (0.1 logMAR on average), which is in contrast to Deruaz et al.[30], who reported a significant improvement (P = 0.022) in distance VA after EV training administered using a SLO, and this may be owing to their usage of SLO in their training and its accuracy in detecting the best PRL[30].

Many other studies were in agreement with us, as they reported no significant change (P > 0.05) in distance VA after EV training[12],[16],[17],[29].

Clearly, there is no proof of the effect of EV training on distance VA, and more work is required.

In our study, we compared between two groups of patients: 17 patients were trained for using the best direction of EV with the appropriate optical low-vision device with the suitable magnification for near and far vision for every patient (group 1) (51.5%) and 16 patients were trained for using the best direction of EV with nonoptical low-vision devices (large print size) for reading and EV only for far vision (group 2) (48.5%) [Table 3].

After 2 months, we found that the group that used low-vision devices with EV training (group 1) showed significant improvement in the near BCVA (0.41 ± 0.17) than the group that used EV training only (group 2) (0.78 ± 0.28). The group that used low-vision devices with EV training (group 1) showed also significant improvement in the far BCVA (0.75 ± 0.17) than the group that used EV training only (group 2) (1.02 ± 0.28).

After analysis of the direction of EV, PRL location by the direct ophthalmoscope, and the visual field in every patient, we noticed that there was agreement between the direction of EV, PRL location by the direct ophthalmoscope, and the visual field in two-thirds of the patients (22 patients) (66.7%) (agreement group), and there was disagreement between the direction of EV, PRL location by the direct ophthalmoscope, and the visual field in one-third of the patients (11 patients) (33.3%).

The agreement group showed significant improvement in the near BCVA and reading speed after training than the disagreement group (P < 0.001), and this result indicates that the agreement between the subjective direction of EV, PRL location by the direct ophthalmoscope, and the visual field results in a more precise location of the PRL, so the patients can be educated for EV easily, and it gives better results after training.

The techniques used in the present study to test and prepare for EV is simple, affordable and efficient for low-vision rehabilitation in developing countries, as it does not require costly equipment.


  Conclusion Top


EV training can be used as a very effective method for low-vision rehabilitation in patients presented with central scotomas, and it can give very good results using simple and inexpensive equipment. The agreement between the subjective direction of EV, PRL location by the direct ophthalmoscope, and the visual field results in a more precise location of the PRL, so the patients can be educated for EV easily, and it gives better results after training.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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