VRT has been validated by 15 years of research with clinical studies published in more than 30 leading journals including Nature Medicine, Neurology, and The Journal of Cognitive Neuroscience. Results of a recent retrospective study of 161 patients from 16 US Centers showed that more than 88% of patients experience improvements in their vision that impact their ability to read, walk, watch TV, and socialize comfortably1. The average five degree improvement in central vision from VRT can make a functional and exponential difference in patients' daily lives, and more than 2,000 patients have been treated. With approximately 20% of all stroke and TBI survivors suffering vision loss2, approximately 2.2 million Americans are living with neurological vision loss1.
Visual Field Expansion
Pilot, Dosimetry
Kasten E., Sabel B. Visual field enlargement after computer training in brain-damaged patients with homonymous: an open pilot trial. Restorative Neurology and Neuroscience. 1995; 8: 113-127
This open pilot describes a computerized training program which may possibly reduce the size of the "blind" visual field in patients with homonymous visual field deficits. Only two of the 11 patients with treatment showed no significant improvement in vision.
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Randomized Controlled Studies
Kasten E., Wuest S., Behrens-Baumann W., and Sabel BA. Computer-based training for the treatment of partial blindness. Nature Medicine 1998; 4: 1083-1087
The results of two independent clinical trials show that, contrary to conventional wisdom, partial blindness after a brain injury is treatable. Computer-based vision training is both a cost-efficient and effective way to improve vision in patients with visual-field defects.
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Prospective Studies
Sabel B., Kenkel S., Kasten E. Vision restoration therapy (VRT) efficacy as assessed by comparative perimetric analysis and subjective questionnaires. Restorative Neurology and Neuroscience 2004; 22:399-420
The study was used to evaluate the efficacy of Vision Restoration Therapy (VRT) in patients with post- chiasmatic brain damage using different functional perimetric tests. These were compared with measures of subjective vision and reaction time.
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Reinhard J, Schreiber A, Schiefer U, Kasten E, Sabel BA, Kenkel S, Vonthein R, Trauzettel-Klinski S .Does VRT Change Absolute Homonymous Visual Field Defects - A Fundus-Controlled Study. British Journal of Ophthalmology, 2005; 89:30-35
The goal of the study was to examine whether visual restitution training (VRT) is able to change absolute homonymous field defect, assessed with fundus-controlled microperimetry, in patients with hemianopia.
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Schreiber A., Vonthein R., Reinhard J., Klosinski-Trauzettel S., Connert C., Shiefer U. Effect of visual restitution training on absolute homonymous scotomas. Neurology 2006; 67:143-145
Sixteen patients were examined with stable homonymous visual field defects (HVFDs) with static automated perimetry (SAP). Training effect was defined as difference of the proportions of absolutely defective locations in all test locations, before and after visual restitution training (VRT).
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Clinical Practice Retrospective Studies
Romano JG, et al. Visual field changes after a rehabilitation intervention: Vision restoration therapy, J Neurol Sci (2008), doi:10.1016/j.jns.2008.06.026
Of patients with stable VFDs due to stroke or traumatic brain injury from 16 US Centers (n=161) who completed 6 modules of VRT, 70 % experienced visual improvements, with an average stimulus detection improvement of 12.8% or a 4.9º border shift between the seeing and the blind field.
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Mueller I., Mast H., Sabel B. Recovery of visual field defects: A large clinical observational study using vision restoration therapy. Restorative Neurology and Neuroscience. 2007;25:563-572
In small experimental trials, vision restoration therapy (VRT), a home-based rehabilitation method, has shown to enlarge the visual field and improve reaction times in patients with lesion involving the CNS. We now evaluated the outcome of VRT in a large sample of clinical patients and studied factors contributing to subjective and objective measures of visual field alterations.
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Stability of Improvement
Gall C. Müller I. Kaufmann C. Sabel B. Effects of long-term use of Vision Restoration Therapy (VRT) and stability of visual field improvements > 3 years. Poster 17 - NANOS 2006
In patients suffering visual field loss after stroke or TBI, VRT for 6 months leads to visual field size increases. When VRT is discontinued, the visual field gains are stable over a period of at least 23 months.
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Kasten E, Müller-Oehring E, Sabel BA. Stability of Visual Field Enlargements Following Computer-Based Restitution Training – Results of a Follow-up. Journal of Clinical and Experimental Neuropsychology. 2001, Vol. 23, No. 3, pp. 297-305
Patients with cerebral lesions can maintain or even increase the significant visual field enlargements induced by computer training (therapy)—even two years after training is discontinued.
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Predictors of Success
Poggel D., Mueller I., Kasten E., Sabel B. Multifactorial predictors and outcome variables of vision restoration training in patients with post-geniculate visual field loss. Restorative Neurology and Neuroscience 2008;26:321-339
Systematic stimulation of the visual field border in patients with visual field loss after cerebral lesion improves visual function even years after the onset of partial blindness.
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Functional Outcomes
Questionnaires and Other Subjective Measures
Mueller I, Poggel DA, Kenkel S, Kasten E and Sabel BA. Vision Restoration Therapy after brain damage: subjective improvements of activities of daily life and their relationship to visual field enlargements. Visual Impairment Research 2003; 5: 157-178
A recent restrospective study shows that Vision Restoration Therapy (VRT) leads to subjective improvements of vision-guided activities in everyday life. Even patients with small visual field enlargements noted subjective improvements in daily life. Subjective benefits identified include walking/mobility, confidence/independence, reading, hobbies/watching TV.
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Gall C., Mueller I., Gudlin J., Lindig A., Schlueter D., Jobke S., Franke G., Sabel B. Vision and health-related quality of life before and after vision restoration training in cerebrally damaged patients Restorative Neurology and Neuroscience 2008;26:341-353
The aim of the study was to examine if improvements of stimulus detection performance in visual field tests after intensive visual training of the visual field border zone in patients with visual field defects are associated with changes in self-reported vision- and health-related quality of life.
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Poggel D., Mueller-Oehring E., Kasten E., Bunzenthal U., Sabel B., The topography of training-induced visual field recovery: Perimetric maps and
subjective representations. Visual Cognition 2008;16:1059
Objective’ visual field topography (perimetry) in 19 patients with postgeniculate visual system lesions and related this to the subjective scotoma representation as expressed by patients’ drawings of the defect and monitored changes of these measures during training-induced recovery of function.
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Attentional Tests
Kasten E., Ulrike B., Sabel B., Visual field recovery after vision restoration therapy (VRT) is independent of eye movements-An eye tracker study. Behavioural Brain Research 2006;175:18-26
It has been argued that patients with visual field defects compensate for their deficit by making more frequent eye movements toward the hemianopic field and that visual field enlargements found after vision restoration therapy (VRT) may be an artefact of such eye movements. In order to determine if this was correct, we recorded eye movements in hemianopic subjects before and after VRT.
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Mechanisms of Recovery
Attention
Poggel D., Kasten E., Sabel B., Attentional cueing improves vision restoration therapy in patients with visual field defects. Neurology, 2004;63:2069-2076
In a retrospective, randomized clinical trial, treatment outcome was compared in patients with postgenicular visual system lesions who received either standard VRT or VRT with attentional cueing for a six-month trial period. Attentional cueing was found to amplify long-term neuronal plasticity.
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Extra Striate Pathway Activation
Jobke S., Kasten., Sabel B. Vision restoration through extrastriate stimulation in patients with visual field defects – a double-blind and randomized experimental study. Society of Neuroscience 2007
In this cross-over study, 18 patients with visual field defects with prior VRT experience were treated with two training paradigms. Group 1 (n=8) first used extrastriate VRT (e-VRT) followed by conventional standard-VRT. Group 2 (n=10) trained in reverse order. Visual field size was assessed with computer-based perimertry and subjective vision with the NEI-VFQ questionnaire.
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Neuroimaging
Marshall RS, Ferrera JJ, Barnes A, Zang X, O'Brien KA, Chmayssani M, Hirsch J and Lazar, RM. Brain Activity Associated With Stimulation Therapy Of The Visual Border Zone In Hemianopic Stroke Patients. Neuro Rehabilitation Neural Repair. 2008 2,Epub 2007 Aug 14.
A functional magnetic resonance imaging (fMRI) study performed by researchers at Columbia University Medical Center on patients who have lost vision from stroke or brain injury shows that by performing Vision Restoration Therapy (VRT) the patients had an increase in brain activity.
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Julkunen L., Tenovuo O., Voroby V., Hiltunen J., Teräs M., Jääskeläinen S., Hämäläinen H. Functional brain imaging, clinical and neurophysiological outcome of visual rehabilitation in a chronic stroke patient. Restorative Neurology and Neuroscience 2006;24:123-132
The purpose was to study the rehabilitation outcome in a chronic visual field defect patient using positron emission tomography
(PET) imaging, clinical, and neurophysiological measures.
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Do Eye Movements Play A Role in Visual Field Expansion?
Microperimetry
Chmayssani M., Minzer B., Saxena N, Arogyasami R, Lazar R, Greenstein V., Marshall R. Retinal Microperimetry as a Means to Assess Visual Field Expansion in Visual Restoration Therapy. AAN 2008
The study used Micropermetry (MP-1) to test the hypothesis that expansion of visual field following VRT is independent of eye movements.
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Blind Spot Stability
Marshall R., Schulz P., Kenkel S., Romano J. Stability of the Blind Spot as a Measure of Fixation Stability in Visual Restoration Therapy. AAN 2008
Twenty-seven patients with centrally- caused homonymous field defects underwent VRT daily for 6 months. Monocular high resolution perimetry (HRP) was performed before and after therapy.
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New Indications
Jung C., Bruce B., Newman N., Biousse V. Visual function in anterior ischemic optic neuropathy: Effect of Vision Restoration Therapy - A pilot study. Journal of the Neurological Sciences 2008;268:145-149
The objective of the study was to evaluate the effects of Vision Restoration Therapy (VRT) on the visual function of patients with anterior ischemic optic
neuropathy.
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Gulin J., Mueller I., Solon T., Sabel B. Computer based vision restoration therapy in glaucoma patients: A small open pilot study. Restorative Neurology and Neuroscience 2008;268:145-149
Several studies have shown that computer-based visual stimulation improves detection performance in brain
damaged patients with post-chiasmatic lesions after stroke or trauma. Because it is not known whether visual field defects after
retinal lesions can also be modified by visual stimulation we explored if visual field enlargements are possible in patients with
glaucoma.
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