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People with Hemianopia Report Difficulty with TV, Computer, Cinema Use, and Photography

Costela, Francisco M., PhD1,2*; Sheldon, Sarah S., BS1; Walker, Bethany1; Woods, Russell L., PhD1,2

Optometry and Vision Science: May 2018 - Volume 95 - Issue 5 - p 428–434
doi: 10.1097/OPX.0000000000001215
Original Investigations

SIGNIFICANCE Our survey found that participants with hemianopia report more difficulties watching video in various formats, including television (TV), on computers, and in a movie theater, compared with participants with normal vision (NV). These reported difficulties were not as marked as those reported by people with central vision loss.

PURPOSE The aim of this study was to survey the viewing experience (e.g., frequency, difficulty) of viewing video on TV, computers and portable visual display devices, and at the cinema of people with hemianopia and NV. This information may guide vision rehabilitation.

METHODS We administered a cross-sectional survey to investigate the viewing habits of people with hemianopia (n = 91) or NV (n = 192). The survey, consisting of 22 items, was administered either in person or in a telephone interview. Descriptive statistics are reported.

RESULTS There were five major differences between the hemianopia and NV groups. Many participants with hemianopia reported (1) at least “some” difficulty watching TV (39/82); (2) at least “some” difficulty watching video on a computer (16/62); (3) never attending the cinema (30/87); (4) at least some difficulty watching movies in the cinema (20/56), among those who did attend the cinema; and (5) never taking photographs (24/80). Some people with hemianopia reported methods that they used to help them watch video, including video playback and head turn.

CONCLUSIONS Although people with hemianopia report more difficulty with viewing video on TV and at the cinema, we are not aware of any rehabilitation methods specifically designed to assist people with hemianopia to watch video. The results of this survey may guide future vision rehabilitation.

1Schepens Eye Research Institute, Massachusetts Eye and Ear, Boston, Massachusetts

2Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts *Francisco_costela@meei.harvard.edu

Supplemental Digital Content: The list of questions asked in our survey can be found in the Appendix, available at http://links.lww.com/OPX/A341. There were five questions related to TV viewing habits, two about portable devices, seven about computer use, two about the cinema, and six questions about photography.

Submitted: June 5, 2017

Accepted: March 7, 2018

Funding/Support: National Institutes of Health (R01EY019100; to RLW) and Core grant P30EY003790.

Conflict of Interest Disclosure: No conflict of interest reported.

Author Contributions: Conceptualization: RLW; Data Curation: SSS, BW; Formal Analysis: FMC, SSS; Funding Acquisition: RLW; Investigation: FMC; Methodology: FMC, RLW; Software: FMC; Supervision: FMC, RLW; Validation: FMC, RLW; Visualization: FMC, RLW; Writing – Original Draft: FMC; Writing – Review & Editing: FMC, RLW.

Supplemental Digital Content: Direct URL links are provided within the text.

Figure

Figure

Hemianopia is a cortical blindness, most commonly from stroke, which usually eliminates vision on one side in both eyes (homonymous), thus reducing visuospatial perception. This vision impairment diminishes the quality of life and negatively impacts activities of daily living, such as noticing other persons,1 reading,2,3 walking,4,5 and driving.3,4,6–9 Another activity that may be severely affected is watching television and other forms of video (e.g., computer, portable devices, cinema). A previous survey of 46 people with hemianopia and quadranopia, which included one question about television, found that 30% reported some difficulty with watching television.10 Such difficulties could arise from information missed due to the scotoma, eye movement control including compensatory scanning, and reading problems when text is presented. This may lead to difficulty following the story and a consequent reduction in value from the viewing experience.

The prevalence of homonymous visual field defects has been reported as 0.8% in the general population over 49 years of age.11 As there were about 100 million people 50 years or older in the United States in 2010,12 this suggests that there were about 800,000 people in the United States with a homonymous visual field defect. The proportion of visual field deficits can be as high as 49% in an acute stroke care setting,13 although many visual field deficits resolve in 1 to 6 months.14 Of stroke survivors, 8%11 to 16%15 have long-term hemianopia, most of which are partial or complete homonymous hemianopia. As there were 6.2 million stroke survivors in the United States in 2010,16 this suggests that between half million and one million stroke survivors in the United States have a permanent hemianopic visual field deficit, which is consistent with the other prevalence estimate above.

Risk of hemianopia increases with age, as does the time watching television. People 65 years or older in the United States watch more than 49 hours of television a week on average.17 Therefore, it is important to understand the scale of this problem, to investigate its causes, and to develop treatments or aids. Many rehabilitation strategies have been adopted for people with hemianopia, including vision restitution (or restoration), compensation (e.g., scanning training), and substitution (e.g., prisms),18–26 with evidence of benefit from some21,24,27 but not all20,26 recent randomized trials. There is dearth of literature about rehabilitation aimed at people with hemianopia watching television, even though this is a reported difficulty.10

In the United States, hemianopia is not generally considered a vision impairment, and people with hemianopia do not usually obtain any government assistance at a Federal or state level. Even so, people with hemianopia are not able to hold a driver's license in many states. The situation differs in other jurisdictions, with hemianopia being considered a vision impairment in some and thus entitled to forms of assistance. In certain jurisdictions, driving is allowed, usually after a driving evaluation. People with hemianopia are often not referred to vision rehabilitation services by primary care, neurology, or neuro-ophthalmology. Given that there are about half as many people with hemianopia (about 0.8 million)11 as people with central vision loss with visual acuity 20/70 or worse (about 1.5 million),28 we might expect people with hemianopia to be about one-third of the patients in vision rehabilitation clinics. However, in our experience, the actual proportion is considerably lower.

Here, we report the first systematic survey of people with hemianopia (n = 91) that is focused on watching video in various formats, including their viewing habits, the difficulties that they experience, and compensatory strategies that they use. Items from a previous survey of people with central vision loss were used.29 As people with hemianopia had reported difficulties taking photographs to us, our survey also included questions related to their habits taking photographs. We included 192 people with normal vision as a control group.

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METHODS

Survey

The viewing-habits survey was similar to a previous survey that investigated the viewing habits of people with impaired central vision.29 It was administered either in person (n = 22) or as a telephone interview (n = 69). Verbal consent from each participant was obtained for the telephone-administered survey after the study was explained, and the consent form was read out. Written consent was obtained from participants who took the survey in person. In addition to demographic and clinical questions, there were five questions related to television viewing habits, two about portable devices, seven about computer use, two about the cinema, and six questions about photography. The items of the survey can be found in the Appendix, available at http://links.lww.com/OPX/A341. Data collection was administered by an examiner who recorded verbal responses using a custom computer interface. The viewing-habits survey took about 10 to 15 minutes to complete.

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Participants

Of the 283 participants, 192 had normal vision, and 91 had some form of hemianopia. These participants were primarily from Massachusetts (111/192 normal vision and 68/91 hemianopia). People with hemianopia came from three sources: (1) people who had participated or expressed a willingness to participate in studies at Schepens Eye Research Institute (n = 79); (2) had been patients at Massachusetts Eye and Ear Infirmary, Boston, MA (n = 10); or (3) volunteered in response to advertisements placed on the ResearchMatch.org Web site (n = 2). For the survey, hemianopia was documented as lack of vision by quadrants. So, a participant with hemianopia would have two quadrants with missing vision, except for the two participants with bitemporal hemianopia (Table 1). Some of the participants did not have complete hemianopia, having some vision beyond the midline, but the majority of the visual field was missing in both quadrants. For the participants seen at the institute, visual fields were measured with a Goldmann perimeter. For participants interviewed by telephone only, some were able to provide visual field measurements, whereas the rest answered questions about their ability to see in the four quadrants. Participants from Massachusetts Eye and Ear Infirmary were identified using a billing code (International Classification of Diseases, Ninth Revision) for homonymous hemianopia. Potential participants with hemianopia who reported physical disability that might affect their ability to view video were not included. See Table 1 for descriptive demographic and clinical information of all the participants. In our survey sample, the reported cause of hemianopia was similar to previous studies,11,14,30 with 61% stroke, 11% traumatic brain injury, 13% a tumor, and 11% a consequence of brain surgery.

TABLE 1

TABLE 1

Participants with normal vision had visual acuity with both eyes of 20/30 or better and self-reported normal vision (using a questionnaire). Some participants with normal vision had visual acuity in one eye that would not be considered normal vision on its own (e.g., 20/200 in the right eye). However, those participants had good visual acuity when viewing with both eyes and full visual fields (e.g., 20/20 for that example participant), so had functionally normal vision (as daily activities are usually conducted with both eyes open). Analyses without these participants with one eye worse than 20/30 did not alter the interpretation of the outcomes reported below.

As shown in Fig. 1, the number of younger (20 to 35 years) and older (75 to 85 years) participants was greater in the normal-vision sample (Kolmogorov-Smirnov two-sample, P = .02). Age was included as a covariate in analyses. There were no differences in education (P = .23) or gender (P = .14) between the two groups. The participants with hemianopia were more likely to be white compared with the normal-vision participant group (P = .003).

FIGURE 1

FIGURE 1

This study was approved by the Institutional Review Board of Schepens Eye Research Institute.

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Statistical Analyses

Data from the FileMaker Pro survey database were exported into the Stata statistical package (version 14; Stata, College Station, TX) for data analysis. Comparisons between the hemianopia and control groups for the survey questions used logistic regression and ordered logistic regression as these allowed inclusion of the covariates age, education level, and gender. Because we performed many statistical analyses, P ≤ .01 was considered statistically significant. As our sample size was not large (n = 283), effects that approached significance (.01 < P ≤ .10) are also noted.

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RESULTS

The main aspects of the viewing-habits survey responses are summarized in Table 2. As illustrated in Fig. 2, responses of participants with hemianopia were significantly different from participants with normal vision for many items.

TABLE 2

TABLE 2

FIGURE 2

FIGURE 2

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Television

The median amount of television watched per day was 2 to 3 hours and was not different between the two groups (ordered logistic regression, z = 1.00, P = .32). As reported previously,29 the number of hours of television watching increased with age (z = 2.83, P = .005), and that did not vary significantly between the groups (z = 0.60, P = .59). Frequency of viewing reduced with increasing level of education (ordered logistic regression, z = 3.64, P < .001) and tended to be more for male participants (z = 1.76, P = .08). Four participants with hemianopia and three with normal vision reported watching no television (0 h/d). When watching television, 58% of people reported that their viewing occurred when there was usually no other viewer (“sometimes” or less). Participants with hemianopia were slightly less likely to watch television with others (ordered logistic regression, z = 1.90, P = .03), regardless of age (z = 1.31, P = .19). Conversely, participants with normal vision decreased the likelihood of watching in the presence of another viewer with increasing age (z = −2.46, P = .01). As shown in Fig. 2A, participants with hemianopia (58%) were more likely than participants with normal vision (18%) to report at least “some” difficulty watching television (ordered logistic regression, z = 4.57, P < .0001). There was no change with age in reported difficulty watching television (z = 0.91, P = .36). Comments about the experienced difficulties included not seeing things of interest on the blind side and difficulty with specific viewing situations (e.g., following ball path to right-handed batter in baseball, tennis, fast action) and with text, particularly scrolling text. Participants with hemianopia (30%) were more likely than participants with normal vision (6%) to report the use of a special strategy, assistive device, or visual aid while watching television or movies (logistic regression, z = 3.12, P = .003). The 24 participants with hemianopia who reported an assistive strategy for watching television reported (numbers add to >24, as some participants reported more than one strategy): only watching with a spouse who could assist with understanding (n = 2), using a video storage device such as a DVR or TiVo (allows going back to review segments, n = 4), compensatory scanning (n = 3), glasses specifically for television (n = 3), closing one eye (n = 2), tilting the head (n = 2), turning the head or looking to the side (n = 3), sitting to one side (n = 4), and using closed captions (n = 2). Six reported using peripheral prism glasses, and one reported that he/she did not help for viewing television. This survey was not able to assess whether these approaches provided real benefit, and it was not obvious to us how some of the reported strategies might help. We presume that a viewer would continue with the use of a strategy only if it was perceived to provide a benefit to him/her.

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Portable Devices

Most participants (73%) reported never using a portable device (e.g., iPhone, personal DVD player) to watch videos, with no difference between the groups (logistic regression, z = 0.74, P = .46). Older participants (z = 4.08, P < .001) and females (z = 1.94, P = .05) were less likely to have watched video on a handheld device. Of the 51 participants who reported watching video on handheld devices, there was a tendency for participants with hemianopia (22/29 reported “never”), as compared with participants with normal vision (10/22), to be less likely to report that they had difficulty seeing details (ordered logistic regression, z = 1.94, P = .05). It is possible that this outcome was a result of selection bias, with only those with hemianopia who were able to use a portable device to view video providing a response about difficulty.

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Computer

Most participants (86%) reported having a computer at home, with no significant difference in availability between the two groups (ordered logistic regression, z = 1.06, P = .29). Older participants with normal vision were less likely to have a computer at home than younger participants (z = 2.45, P = .01), but there was no effect of age among the participants with hemianopia (z = 0.13, P = .90). Of the participants reported to have a computer at home, only 39% of the normal-vision participants and 30% of the participants with hemianopia watched movies (e.g., DVD) on the computer. Frequency of viewing movies on a computer decreased with increasing age (ordered logistic regression, z = 4.11, P < .001), with no difference between the two groups (z = 0.61, P = .54). Most participants with Internet access (127/191) reported watching Internet video content (e.g., YouTube, Hulu, television shows from network Web sites), with no difference between the groups (z = 0.16, P = .88) and frequency declined with increasing age (z = 6.74, P < .001). Among those people watching video materials on computer, it was uncommon for there to be another viewer present, with only 23 of 157 reporting another viewer often or always present, with participants with hemianopia tended to be less likely to have another viewer present (ordered logistic regression, z = 2.30, P = .02). Among participants with normal vision, the likelihood of having another viewer present decreased with age (z = 4.07, P < .001), whereas there was no variation with age among the participants with hemianopia (z = 0.12, P = .91). Participants with hemianopia (26% at least “sometimes”) were more likely (ordered logistic regression, z = 2.56, P = .01) to report having difficulty with details on a computer screen than normal-vision participants (7%), with no effect of age (z = 0.37, P = .72). More than a quarter (14/62) of the participants with hemianopia who used a computer reported at least “sometimes” to use assistive technologies, which was more than the 2% of the normal-vision participants who reported using assistive technologies (z = 2.32, P = .02). Older participants tended to be less likely to use assistive technologies with the computer (z = 1.93, P = .05). The reported assistive approaches were reducing viewing distance (n = 3), increasing mouse icon visibility (n = 3), large font size (n = 2), zoom software (n = 2), and reading software (n = 1). We are not aware of assistive technologies designed specifically to assist people with hemianopia in the use of computers.

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Cinema

About three-fourths of participants reported watching movies in a cinema, with most going to movie theaters a “few times a year.” Frequency of attendance decreased with age (ordered logistic regression, z = 3.48, P < .001), and participants with hemianopia reported lower frequency (z = 2.80, P = .05). In particular, participants with hemianopia (34%) were much more likely (logistic regression, z = 3.56, P < .001) to report never attending the cinema than normal vision (19%) (Fig. 2C). As shown in Fig. 2B, participants with hemianopia (31/72) were more likely to report at least “some” difficulty watching movies in a cinema (ordered logistic regression, z = 4.73, P < .001) than participants with normal vision (7/92). Turning the head (n = 2), sitting to one side (n = 3), compensatory scanning (n = 2), and peripheral prism glasses (n = 1) were reported as strategies to improve the viewing experience. Reasons for never or very infrequently attending the cinema or difficulties when attending included reports of missing information (n = 4) or missing objects on the blind side (n = 2) making it difficult to follow the story, the very large cinema screen (n = 4), fast action (n = 4) or reading text on the screen (n = 2), and uncertainty about being able to obtain a preferred seating location (to the back so that the screen subtends a smaller visual angle or on the blind side of the cinema, so that the screen is on the seeing side).

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Photography

Many participants with hemianopia (24/80) reported never taking photographs, which was more likely than among participants with normal vision (logistic regression, z = 4.93, P < .001) (Fig. 2D). Overall, participants who had hemianopia (ordered logistic regression, z = 2.02, P = .04), were older (z = 4.10, P < .001), had less education (z = 2.40, P = .02), and were male (z = 1.80, P = .07) took photographs less frequently. Of those who did take photographs, there was neither difference between the groups (z = 1.33, P = .18) nor an effect of age (z = 0.20, P = .84) in the difficulty taking photographs (note that this subset was biased, as those who had most difficulty did not take photographs). Participants with hemianopia who expressed difficulties described problems locating the picture target using the device (14%), understanding the technology (20%), placing the picture target at the desired location in the picture (9%), fitting multiple targets in the picture (7%), and issues related to lighting or focusing (18%). Some participants with hemianopia reported not taking photographs because of cognitive problems (e.g., cannot find camera, difficulty operating the camera) or physical problems (e.g., tremor) and because others take the photographs instead (or take better photographs). Sharing of photographs was less frequently among older participants (OLR, z = 3.24, P = .001) and participants with less education (z = 2.55, P = .01) and did not vary between the two groups (z = 0.00, P > .999).

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DISCUSSION

Most (56%) of the participants with hemianopia reported at least “some” difficulty watching television, which was much higher than among participants with normal vision. Similarly, a previous, smaller survey10 reported that 30% of participants with hemianopia reported difficulty with “following the action in programs” on television. In our survey, similar difficulties were also reported with related activities, watching video on a computer and movies at the cinema (Table 2, Fig. 2). Participants with hemianopia were much less likely to watch movies in a cinema and much less likely to ever take photographs. The lower rates of cinema attendance and photography were presumably because they found these tasks more difficult compared with people with normal vision and thus suggest that their vision impairment may make them refrain from engaging in these activities. While the difficulties leading to this reduced activity may not be all visual and could be from other factors such as cognitive or physical impairment, this population has reduced engagement in these activities. Conversely, despite reporting more difficulty watching television, participants with hemianopia reported watching slightly more television. Perhaps this reflects a reduction in other activities due to the vision impairment and that additional available time is used to watch television, as it is an easy option.

If we accept the estimate of 500,000 to 1,000,000 people with hemianopia in the United States11,12,14,15 and that our survey was representative of that population, this suggests that between 280,000 and 560,000 people with hemianopia in the United States feel that they have difficulty watching television. Although self-reported difficulties with activities of daily living, such as watching television, have been previously reported for hemianopia,10 there have been no assessment methods to measure this difficulty. In a separate study that is currently under review, Costela and colleagues provide data which shows that watching video is measurably more difficult for people with hemianopia, using a recently developed method we call sensory information acquisition.31,32 In this approach, information acquisition is a measure of the ability to follow the story. Even when watching video for enjoyment, if you cannot follow the story, the value of the activity is usually diminished.

Half of the participants with hemianopia expressed strong interest in assistive technology. One of the concerns with an intervention that modifies the displayed image is that it may be unacceptable to other viewers watching the same display. Most participants with hemianopia watched television with others infrequently (44/78, sometimes or less). Viewing without another person present provides the opportunity to use a rehabilitation aid that might be unacceptable to a viewer with normal vision. Participants with hemianopia reported that watching television or video on a computer while alone was common, and in a previous, related study, the median number of televisions per home was found to be two.29 People with hemianopia reported a variety of assistive methods (e.g., DVR), but we are aware of no previous reports of rehabilitation methods developed specifically to assist people with hemianopia watch television or video. In a separate unpublished study, Costela and colleagues investigated an innovative rehabilitation method that holds promise for improving the ability to follow the story (improved information acquisition). The approach involves providing a visual content guide to the location that contains most information. It is sufficient to look at this highlighted region to follow the story. The rationale being that the viewer no longer has to look into the blind side to check whether there are objects of interest (compensatory scanning) and that looking away from the object of interest to make a compensatory scan disrupts the ability to follow the story. If the highlighted region was not visible, then the viewer would know that the object of interest was on the blind side and make a gaze shift to locate the highlighted object of interest. However, viewers with hemianopia tend to follow the dynamic content guide effectively and do not usually lose it into the blind side.

Central vision loss (reduced visual acuity) is the most common form of low vision. Here we briefly report some differences and similarities in the responses of 116 participants with central vision loss (visual acuity of 20/60 or worse), most of whom participated in a previous study,29 to our participants with hemianopia. Participants with central vision loss reported similar frequency of television viewing (z = 0.15, P = .88), more difficulty watching television (z = 8.35, P < .001), less use of assistive strategies (z = 1.99, P = .05), but more interest in enhancement technologies for television and movies (z = 6.73, P < .001). Participants with central vision loss tended to be less likely to have a computer at home when corrected for age (z = 1.87, P = .06), were as likely to watch movies on a computer (z = 0.96, P = .34) or use the Internet (z = 0.93, P = .35), reported more difficulty viewing movies and video on a computer (z = 4.92, P < .001), were more likely to report using an assistive technology when using the computer (z = 3.65, P < .001), and were more likely to be interested in enhancement technologies for use when watching movies and videos using the computer (z = 6.93, P < .001). Overall, participants with central vision loss had a similar frequency of cinema attendance (z = 1.41, P = .16) but tended to be less likely to never attend (z = 1.65, P = .10).

In summary, our survey found that participants with hemianopia report difficulties watching video in various formats, including television, on computers, and in a movie theater. While these reported difficulties were not as marked as those reported by people with central visual loss, the reported difficulties were greater than those reported by participants with normal vision. These difficulties seem to lead to reduced attendance at movie theaters and reduced taking of photographs. These changes in behavior and difficulties with activities of daily living are related to a reduced quality of life experienced by people with hemianopia that may not be well captured by various instruments3,4,6,8,10 and warrant further investigation.

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