Stroke SIG: Vision Loss After Stroke Episode 4
Hello and welcome to the stroked. Special interest group podcast. Today we are looking at to be joined by two great guests will be talking to us about vision. Impairments following stroke. Our first guest is dr kathleen degree dr kathleen degree is a neurologist. Neuro ophthalmologists and is board certified. As a doctor of headache medicine. She works to the university of utah medical center and founded the neuro service at the university of. Utah's john aymaran ice center where she practices. She specializes in neuro ophthalmology and headache. Where she evaluates and treats complex visual complaints which can be due to optic nerve or brain diseases doctor degree sees patients with complex neuro ophthalmology disorders such as dima photo phobia visual loss and appropriate as well as migraine headaches and unusual headache disorders doctor degree teaches at the university of utah medical school as professor of neurology and ophthalmology. She is the chief of the division of headache. In ophthalmology as well as an adjunct professor of obstetrics and gynecology she recently was appointed to the rank of distinguished professor at the university of utah for her achievements that exemplify the highest goals of scholarship. She has authored over two hundred peer reviewed articles chapters and reviews in addition she has served professional associations as a past president of the north american neuro society and is the current president of the american headache society. Welcome dr degree. First question we have for you is what is neuro ophthalmology. And how is it. Different from ophthalmology relation in relation to stroke neuro ophthalmology of the brain. And the i and since most of the brain serbs vision. A lot of the brain serves vision There are always visual consequences to stroke and I would just say that. I'm a neurologist. That does neuro ophthalmology but we have ophthalmologists that also do neuro ophthalmology and all of us no matter whether you're ophthalmology trained neurology trained or both See visual consequences of stroke are second-guessed is casey mitchel. Casey holds a master's degree of occupational therapy from the university of puget sound and a graduate certification in low vision rehabilitation from the university of alabama at birmingham. Casey currently works in euro specialty outpatient clinic for inter mountain healthcare where he with a variety of clients with neurologic injuries. Many of whom have vision impairments. Casey also works for the miranda is center working with low vision and neurologically impaired vision patients. Casey has been occupational therapist for over sixteen years with an emphasis in neuro rehab and enjoys the challenge of working with clients who have multiple diagnoses in order for them to achieve greater independence and quality of life. in addition he's an adjunct professor for the university of utah in both the department of social and recreational therapy in department of ophthalmology and visual science. Casey you have some specialized training in vision therapy. Can you describe to us a little bit more in detail. So my background is in Low vision is vision. Can't be corrected anymore. And then i recently worked in a clinic. We work with brain injury patients stroke and then also people who have acquired brain injury. And so i. I've taken some courses on mickley brain injury in vision. And then i i have a a a graduate certificate in low vision and so that was just kind of a study of the visual system and so then you know integrating vision into treatment. Vice versa is really key so that sounds great. Thank you both for joining us. Doctor degree could you remind us briefly of the visual pathways in anatomic structures most associated with vision that could be affected after a stroke and there was already quite a few. Yeah well first of all the eye itself can be affected by vision by visualize with stroke and that's with central retinal artery inclusions ranch retinal artery inclusions and And strokes can come from the anterior or the posters circulation. In if i just a take you through the visual pathway. I i'll just it's the i connected with the optic nerve. And then at the kiosk some there's a crossing that occurs and then the when the crossing is over we have an optic track the takes vision than to the lateral body and then to the cortex and And eventually the exit obita. It all ends up in the exit lobe But it goes from the lateral genetic can go up to the prior to loeb and And down through the temporal lobe and that visual pathway then can be affected by stroke and any one of the places so in the eyeball you can have an anterior stroke that causes. The central are reclusion inclusion or a branch retinal artery exclusion or it can cause an schema to the entire i Through an upsell mc artery exclusion The next place that you can have it which is not really a stroke. But it's like a stroke to the optic nerve which is anterior schemic optic neuropathy it's a small vessel occlusive problem. That occur can occur. Either idiopathic louis or it can occur in associates association with giant cell arteritis and then Going further back to the qasem. Sometimes there are infarctions of the kiosk itself but because the kaya zoom has very rich blood supply is it's not always affected by a stroke per se but the tract optic track lateral genetic hewlett and the middle lobe as well as the branches said. Come from the lateral genetically to the exit. Low could give you visual pathway strokes and these will be hamas visual field defects. Then if you have an and the answer your pathway would give you mostly retinal artery exclusions. And maybe some exclusions of that would affect quadrant defect most of the post cheerier exclusions which are from the post your your circulation. This comes from the vertebral arteries up to basler every into the most terriers cerebral arteries. On can give you a simple lobes strokes and also give you a momma's strokes this poster circulation then can affect the brain stem to give you double vision and the syr bellum which can give you a various types of nice day so you can see that. It's there's an anterior type of pathway. That can give you some visual field. Defects post your pathways give you a visual field defects and then it can give you double vision if it affects the brain stem and staying mus Texas's bellum and abolish. It could cover all all of the pathways. If it was coming from the heart it can be complicated. Yes it can be very complicated. We've seen that in the clinic. I think everyone of us as a thank you for going through that. So concisely and the next question. We have for your doctor degree. Is what subjective complaints should we be on the lookout for it may indicate visual impairments after someone who's had a stroke and that may not actually sound visual impairments or and sound visual impairments but we need to dive in a little bit deeper for okay so a steady was actually done on. What are the complaints. The problems that people have after stroker's just recently published in plus in twenty thousand nineteen and the first thing that seems to be affected central visual acuity in over half of the keys and then that should be a red flag. If you have a little hand held card you're in the hospital or in rehab facility or whatever you need to do visual acuity and if it's not twenty twenty then you've gotta have a reason for why it's not twenty twenty okay and so that's really a big clue that something is going on of the next thing could be double vision People complain of double vision And sometimes they'll complain visual field loss but nature doesn't like avoid so they're unlikely to walk into your office or your clinic or your hospital saying oh i'm having problems with my visual field off the right they're going to just say something's not right in my right eye so that should be a clue to somebody taking care of a stroke then there can be visual inattention or visual perception problems and inattention means that they really don't know what was going on but they may not be paying attention to one side their vision and most people were stroke are going to have something that affects more than one visual category over half of those patients with stroke are gonna affect one of the other have more than just one category and that's why it's difficult it's difficult for us. We have to figure out all the problems that a person has when we see somebody who is a stroke to figure out. Do they have an acuity problem. That's related to Just a refracting issue or is this related to the stroke itself. A physical therapist will usually perform a basic visual screens. am including smooth pursuits. Conversions qods field cuts depth perception and brief acuity. This basic visual screen helps with some visual concerns related to balance problems Or scanning that may affect the person's safety in your opinion which visual impairments are the most important to screen for from physical therapy perspective so i would say That visual acuity. I know you do a brief one but that visual acuity is actually really important. It should be done distancing near but if you only have a near card that can suffice frequently what people forget to do is check the pupils for relative after pupil defect. Because that may be a clue as to where in the visuals system the problem is it. Could be in the optic nerve. I could be in the retina. I and or it could be the tracked. The visual field should be done. Each is individually not both is at the same time but i would check for simultaneous neglect with both eyes open. I agree about pursuit. Cicadas and looking for an miss but i think one of the most important test to do is to do a cover cross cover test which really looks for a misalignment of the eyes at that will cause double vision and will cause a lot of visual confusion for a person and then finally i know most physical therapists. Don't have a way to look at the fundus but that's also important on and then as far as neurologic examination. I know that was physical therapist. Check the cranial nerves. Look for a hemi paris's or himmy please. I don't know how often reflexes are tested. But they're very helpful and then making sure that people can walk or they can't walk. You know what kind of devices they need to be mobile. Yeah that's great Casey do you wanna weigh in on this one two for evaluation that you might think might be helpful and then maybe you guys typically perform. That might be easy enough for us to understand. Absolutely she mentioned really all of them but you know just the stress the importance of acuity like many of the paper pencil tests. That are that are often administered to people strokes if there's any type of acuity problem these penciled tests are really they don't show anything i'm in fact they might you know if if somebody doesn't check carefully they'll give a false positive something else And so you know. The acuity is essential and sometimes you don't have access to in a cutie card just pulling out some something that can read is sometimes gives you an indication so even if you don't have all the equipment you can really give get a pretty good idea of of acuity in a clinic that isn't stocked well And then you know. I really like i like the she mentioned the cover uncover test to because that sometimes some patients have a fauria where you know they'll have double vision but it's only when they're tired or fatigue in apple often bring that out so you know that there might be something more than just you know to the complaint but it kinda helps you figure that out as well and i always just looking for nostalgia the cranial nerves. How they're affected. You see any kind. I worked with a lot of kids with concussions and their visual system should just work very very very efficient in so if there's any kind of little glitches in there. That's that's usually an indication that something is going on. So i would just add you know if you don't have a visual acuity card you could take out You know a phone book a book just a regular book or and then just see. The person was able to read something from the phone book or something. That's kind of a standardized like a bar. A paperback or a magazine with bull's is in in reading the problem with reading. As if you've got certain types of strokes you might wipeout. You're reading so you have to. Maybe even ask about individual letters are just say. Can you just tell me what letters you see on this page. If that's something you see a lot with stroke. Is i work with the years ago. That had asia so he could tell us. And and that's the that's the problem with visual. Sometimes people have to tell you some of these things but covered. He had double vision because we are playing chess and he kept putting the chess piece on the wrong square. And so it was like you know. We didn't put a patch on him in awesome. He could play correctly. So you have to rely in the click especially on just what you see. Our observations are can be pretty accurate. That's great So how do you guys typically assess for deploymenta we talked a little bit about acuity already and field cuts. I think those are some of the things that we struggle with from physical therapy. Not having as much formal education on those So so for visual fields We cover each. I individually and present numbers in all four quadrants of somebody's vision And then each individually. And that i do both is at the same time with simultaneous stimulation. I would say there's a wonderful resource for all listeners Which is the novel library. The neuro ophthalmology virtual educational library novel dot. Utah dot edu. It's comes out with a partnership between the north american neuro ophthalmology society and the university of utah. Eccles health sciences library and this partnership was developed a virtual library in neuro ophthalmology. And in this library you can find out how to do visual fields how to check visual acuity how to do cover crops covered testing how to look at movements huddled pursuits the cads etc so i would urge listeners to check out that library because it has many of the examination tools in the library. It's free open access And nanos just published a piece called nanos next of neuro ophthalmology examination techniques In it's available through your library just ask your library to acquire. It's like Up from stat raff. It's just a like journal type of thing but it's available to health. Sciences libraries and libraries can order it. So it's a great resource both novel and this Nanos next Examination technique curriculum is is really great for your listeners of awesome. It's always great to to compile. More resources in the clinic could can be overwhelming so having those free resources is wonderful. So additional areas of concern. Post stroke are inattention and visual. Perceptual deficits is often difficult to determine concerns related to vision as opposed to something else and insights that that might be helpful for pt. On to tran. Discover some of those differences particularly for therapists who maybe are in more rural settings in have less access to a vision specialists of any kind. Well i'd say i get your exam as best you can Because that will help you at least know what the deficits are. If you can get the exam down a little bit you know the acuity the field the eye movements and then You know if they're still complaining. And i yearn just not seeing what they're complaining about them. Casey is as the master of finding out what's really going on he. He's like a magician. He goes out there and he figures it out so the i know you have lots of pearls that you can share amount won a lot of times. It's just a matter of Just i like. I like to go their homes to do it because you can figure out you know in their own environment. What's difficult for him. And then you know it's really just about cheesy now you know and and for me. It's not so much important. I like to see what how it's affecting their function and then going from there I saw recently that his vision. You described it as like looking through kaleidoscope or is it like looking out a bunch of flies all over the place and for him it just. Is you know you kinda rack. Your brain is any of his vision functional and be honest it really may not be because it's very confusing him so i i'm kind of taking a different approach that we we might just start teaching him blind techniques and see if it makes it easier for him to juicing rather than the other way around Otherwise what would what i would like to do is just see you know. Is there a spot where they have some normal vision and then work from there. Feeding off of that question and what type of impairments would warrant referral to an ot with vision specialty or neuro up the mall. If we do have access to those so i would just seep up Anybody who's got visual complaints that the ophthalmologist europe. Thomas can't really help the ot pt figure out what to do next. Then they should get they should probably go to a neuro ophthalmologist Many ophthalmologists and optometrists are very good. At saying what the visual defects are if the patient's still complaining and nobody can come up with wi. They've got the complaints neuro. Ophthalmologists are detectives and we go after everything at what by the time they get out of our clinics man. They know that they've had their visual system. Completely looked at because we do have other tests that are available. I mean we can look at a visual field of formal visual field. In addition to our confrontation feels we can look in the back of the eye and We can detect amer maladies with elektra ratna grams in multi focal ear jesus and visually vo potentials and fluency nanograms and so we have a. We have a lot of tools that can help. Tell the pta and where where and what going on. But i tell you after a stroke the pt ot is really the place to go because these guys are all all of them. I've ever used especially cases who's amazing are just excellent at helping patients. Try to get their lives back together especially with. This is really hard right. P. to a stroke is really hard on somebody. Your life is different. And you got to figure out how to navigate the world in a different way so i an example of of of when this was done right we had a young man that came to a while ago but he went to just routine eye exam you know. He's complaining about some some problem with with a visual field in the thomas sent him to neuro ophthalmology. They found that he actually had a tumor. That was pressing down. I believe was the optic nerve and once tumor was removed. He still has some visual field deficit. But we are able to help him start again and what was great. As he loved to read at this point he really avoided reading prior to this and he didn't do very well in school but we were able to kind of get him motivated. He was working on got working on his gre. Packets are yes graduate package. Whatever they're calling for but Then he got into a locational program and so it was really fun to see him progress. You really wouldn't have tell. That tumor was removed and is visual. System was had a chance to really. He'll rebound how i find. Ot with vision specialty or a neuro ophthalmologist. If i'm a newer clinician or i'm just transitioning into neuro rehab And i'm i'm trying to find those resources for patients is there to find a neuro ophthalmologist to the north american neuro. Ophthalmology website the anos web dot org and There it says find neuro ophthalmologists. You put in where where you live. And and they give within ten miles fifty miles one hundred miles. Two hundred miles whatever but All of those are to help you find a neuro ophthalmologist unfortunate with. Ot were not organized. So we're kind of new for us to be envisioned or at work with vision. And so we're right now. Trying to take on his instances. I can give them as as as much education in terms of of occupational therapies relationship. Division as possible so there are a number of schools and sometimes that's the best way to go. I i did low vision training of alabama. And there's also envision in kansas city sometimes graduates from these programs will know where there are some resources or where people have habit. So we're really trying to get more out there but right now. Unfortunately there's not a ton of us so so moving onto prognosis now Doctor degree what is the most common visual impairment stroke. Well visual acuity. And so and. I can't stress this enough. Because let's say you have a field defect but let's say you need glasses. Got something we can do. I mean that's i. I wanted to see start visual acuity because if we get people seeing the best that they can see with what. They've got laughed. That's that's doing a great job for them. And i see. Qc is in agreement with this key. See yes and then And then i think the thing you know if it's a this will feel fact That's where key see and a physical therapists occupational therapists could be very helpful in helping patients figure out how they're going to navigate their world. And and what this means to their lives. If it's double vision. I try to put in prisons into their glasses. You know because. I can put a stick on prisonment sir glass and the that might take care of their double vision and the good thing about strokes in general. This is an in general is they. Do get a little bit better with time i would say. Sometimes i've seen people get better progressively overhaul year and so i always encourage people to not give up right away because things tend to get better with time and the brain is wonderful at trying to help you deal with whatever deficit you have. That's why we got great brains and got brain. That can help a navigate through a different pathway of people will see better. I'm so i think diagnosing and seeing what the defects are getting the best prescription lens for the patient and then And then if we can do some double vision work. If we can't sometimes what i do as i call it. My magic scotch tape treatment Instead of a pirate patch. I just put scotch tape over. One lends get rid of the double vision so that they can at least navigate. Imagine having to work with two images all the time that would drive anybody crazy and if they've got a lot of nice stag mus seeing if you can find a position where they're nice statements isn't quite so bad. That sometimes can be helpful too. So that's kind of what i do is refraction presumes I try to you know. Make sure that they know what they're defects are and some people don't can't see their defects but their family members see him kozaru. They've got neglect door You know they've got impairments that they can't recognize so and then i did. I definitely make a pt ot referral. Because i feel like at pt ot for me is wonderful because they can help work with the vision to get function into their lives with visual acuity on working with our our speech therapists in our in our clinic Going through some of their cognitive tests that have a visual component. And that's we just went through a bunch of Incessant and that's and that's really what i came up with If they do a quick and dirty visual acuity tests then they'll know if what they're seeing in. The cognitive assessment is real. If not they're going to get a false positive for cognition and it's just a visual problem If all need his glasses man. that's fantastic. Is that something you can change other times. You're kind of dependent on You know what how much damage there is to their cognition like so somebody that has neglect versus just a hemi anoxia. You can teach somebody to scan for missing. He'll they haven't neglect there as well. You're going to have to recruit their whole family friends. And it's going to take just more repetitions than you can possibly provide. So you've got to recruit family if them looking to the sign looking to the second side all the time and so you know all those kind of things. I've been trying something with with double vision where we do like a ler scotch tape thing so all have to turn their head and they cover up vision with one science so you know. There's some tricks like that help. People function just dealing. That are great. You just can't tolerate double vision. Just is so hard coggins Pushes you into cognizance. So if you can take that away even if it's temporary thing it's fantastic for what is the level of spontaneous recovery of vision impairments stroke in doctor degree. You went into that a little bit but if there's anything else you'd like to add a most of the time people improve at it depends on what defect they have but But but they never usually never get back to baseline. unless it's just a moment issue. They might be able to recover from. But if it's a real field defect loser usually pretty permanent They might be able they. Can you know work with pt ot to try to expand that but but there's often a permanent visual loss if it's a visual field defect diplo pia can or cannot improved depends on where the lesion is. And what how big it is. I'm that's my assessment on that so casey. This one's directed toward you when is the prognosis for functional improvement for field loss visual perceptual deficits to africa. Just talk to that affirmative functionally. You know i think a lot of it depends on just how severe in how how much of a cognitive component is. If somebody has for example somebody has a neglect that makes you know overcoming the field cup much more difficult. If it's just a field you can teach somebody to scan. Pretty effectively is a pretty dramatic seal. You can teach them how to scandal that side the point where they start safe or more safe you can also teach families things like sighted guide to give him through that initial part where they're more comfortable going out because that's one of the things that i always worry about is you know. I don't want people to barricade themselves in their own because they're scared to go out and so if you teach family how to help them and then eventually teach them how to train somebody else of grabbing elbow in leading around that in itself makes it so they can go out into public Those kind of things are are pretty good. I i find that most people you know they will get better with time things it easier to get used to it. Their brain adapts to some degree in. Our job is really facilitate. How is there a way to get them to a point where they are functional and more comfortable with their impairment as quickly as we can and so. That's where we use tricks. And that's where we use teaching to the family Those kind of things so again in relation to the pregnancy how these impact the basic. Adl's i-i've in particular driving. I know that's always the million dollar question. It is everybody that has any kind of visual problem. They're always asking about driving and and some of its some of the answers to that are pretty easy if somebody has a ninety degree field their of driving. I mean they just don't have enough visual field the safe and that's kind of an assessment we do. I've got one particular client that has As a pretty significant visual field loss he got started. Getting returning isn't any as far periphery. But he's he. Has this gap right where you would look for opposing traffic. And so even though. It's a smaller. I tell them that if it were if he were missing the field were all the way to the side. You probably hasn't division to drive where it's the location of the field cut. Just wouldn't wanna ride with him. So i teased him that if he decides to drive Homage like take the bus so now. That's the kind of thing you know you. You have to work through some these issues because people really want to drive And and sometimes the answer is just no now in terms of basic eight yells. You can teach people how to do things really with very little vision and there's usually enough motor memory in things like that. They can get back to those cents. Sometimes ideals are a little bit more challenging but if you if you take them one at a time you can usually figure a workaround or some type of adaptation that will help them do a semblance of what they were doing before I'm gonna add a follow on question and it can be either of you. How do you guys make the distinction when someone is able to drive again or to take a license away. Vh to just talk through the thought process. Because i know that's always a challenging thing for anybody involved in the care of somebody who's had some visual impairments that ostro. I'll take the first stab. Let casey do the cleanup On that that's a really hard question but again what we do is we assess the acuity in our state has rules about what acuity they have to have visual field. They have to have in order to drive. And then there's different levels of kidney drive you know on a freeway or can you drive here and there and but there are levels of in our in our state and each state is got different rules. So you gotta know what your rules of your state are if it's a a homonym defect meaning the whole visual field to one side or the other is out. That's pretty much. You know what that's just not going to work and if it's an inferior quadrant stroke that is usually not gonna work if it's superior quadrant. Sometimes those people can't drive because they can safely see what's below them. If it's just one i Often the those people could drive and then we always have a backup of our ot and pt. So if we don't know and we're worried we just call up our pt and ot and they do a driving evaluation and we love that because we go you know what maybe you meet the criteria for driving. But i wanna make sure you're safe to drive. And then they have to go through a driving evaluation and then. I handed over to pt ot to do that. Driving avail. casey. I do something kind of similar in the clinic. I work and we have a drive-in specialist. And i know sugarhouse were dark. Agree sends a lot of her patients on. They also have a driving specialist. So i'll work with somebody in to will all take him through tests like is there visual reaction time sufficient. How about the problem solving. Do they have the emotional stability. The drive you know we had one client not too long ago. That met all the criteria but i was really scared that he was gonna follow somebody home to cut him off and you know his anger was just there so that person worries me even though he meets other criteria. And so. But you know we kind of do the same thing. I will get somebody to the point where. I checked all the boxes. You know they can react fast enough. They a they appear to have the acuity their field seeing good then. I sent him to somebody. That's been doing this for a very long time specifically in driving and they take him through a battery of tests and then they will take him out on the road to see how they handle the stress of driving. And that's kind of what we do and it's it's a fun thing to see somebody that didn't really leave. Could get back to driving. Prove you wrong and it's really quite uncomfortable thing to tell somebody that really wants to drive. Just it's not a safe thing for them to do and it's likely never going to be to treatment. What our options for treatment for visual field loss well You know there's been all kinds of people who tried to come up with Algorithms for visual fields and putting an charging a lot of money to pay attention Again i will rely on my pt and ot for helping on the visual field. The most and really visual field is just. It's about getting that repetitive. Scanning i i like to put somebody initially when i'm doing the training like to you know. Get them looking to the affected side in elected. Set it up on a cadence so every time there right foot goes down low to the right and i just do things very very. Repetitively is even even those who have a visual field. Loss known aglet their brain tends to give the the feeling that they have a full visual field. And so it's it's you know it's neglect is more obvious than that or more difficult to overcome but even somebody that has a pretty significant field cut their brain tends to operate like no. I see everything. I'm fine and so it is just doing something very repetitive. To get him to move over to that side. Get a looking to that side and so set up all kinds of scenarios to help them learn that Recruit family. I recruit other therapists. No so i make sure that their physical therapists on the same team is doing. You know making him address. That affected side speech. Therapy know everybody needs to be on more in terms of helping somebody get consistently looking to the affected side so what are options for treatments for visual perceptual deficits of stroke. That's harder that's a lot harder And again. I think that's where. Pto can help a lot more than me. We can tell people what their issues are. There doubts a lot harder for us to deal with a i kind of called vision. Perception in this is the rocket science vision. I mean people like dr gre- actually understand it. I i really you know it for me. It's just about trying to observe where the deficits are and then trying to work ways around there it is it is so hard Possibly you communicate and just try to get a pitcher through lots and lots of time on of what. Their visual pitchers manifest itself. All over the place. I've got patients dr greaves. She sees all kinds of things like this But you know i have. I had one guy that i was testing. You know his his Smooth pursuits and mine. Testing target was yellow and just the color yellow set him over the edge. I mean until that point. I'd already lost. He he never came back. And i was just like i felt so bad because like you know my target was yellow. Just send him off but you know sustain color. I mean motion Any of these things can just send a push it too hard on that. First day i've given him a horrible migraine in the eighty. And so you know. Just just learning how much i can ask them to do. Just be very careful. I mean and sometimes i give people what i think is very conservative amount of range of motion exercises or anything like that and i find out later that it was too much. And so it's like you have air on the side of extreme caution because a headache especially visual headache. Just doesn't get much worse when it comes in so in doctor. Degrees caseload is just full of people that are just you know that she helps immensely but still are just so limited by the that head pay so what are treatment options for ocular motilal deficits post stroke. So i've already mentioned stick on prisons two glasses and then you can. If the visual diplo stays the same you could get. You can grind them into a glass and and that's very helpful and if it stable for a long enough time we can refer them for muscle surgery Stood business surgeons can then straighten on people's eyes out if they've got double vision and skew deviations So but i usually. I wait a long time on those because usually they can get a little bit better with time and are you. Don't wanna do surgery or anything drastic. Because people can get better with time we see we see clients occasionally to if you if you add some exercises muscle. I muscle exercises that. Sometimes you can address that and and help them get a little bit better now. It doesn't work for everybody. I mean it depends on like you know the things that i don't understand. The duck agree pointed out earlier of where the damages. How much damage in the brain was done. So some people respond well to treatment and the the double vision resolves over time other people. You know it's just a matter of helping them. Adapt find ways to find single vision and then ultimately opted the surgeons in really make a change in their life host treatment. How much of the moment you feel as related to improvements in lost or altered vision in how much of it is substitution or adaptation to improve the functional ability. Yes is the answer the answer it depends right always i mean you. The goal is to help them return to as close to normal as possible. And then you always end up with a to some degree or another is the double vision may go away but then there might be of perceptual issues. That weren't aware of when you first started. That come up. Are there outcome measures that can document progress throughout therapy that would be valuable for. Pt's obviously we do some. That are very mobility related but are there others that that might be helpful a little bit more vision related or in terms of neuro ophthalmology. Are there things that you would like to see the pt report to you. Specifically i you know will send to the pta. And they'll have my records about what's wrong and And i just i think the pt and ot are so important Are at everybody. That has a stroke. Should see somebody to help them. Overcome their deficits and I don't know of any measures per se If they're not doing well like could. I have missed something in my exam. That i should be working on or You know do. I have the acuity the best i can get it. I mean these are things. I have to always ask myself if they're not doing well and pt and ot. I diagnosed everything. Have i got the best glasses. I got the best exam on them. That i could get in and i rely on. Pd not to say to me. You know this prison still not doing well. Could you just check recheck. That visual field or recheck. This or something like that. I i love it and i think the best outcome measure for us is just returned to function at some point. It doesn't really matter. If their vision has improved. I mean if they can go back and resumed some of the meaningful tasks that they've not been able to do some degrees you know that's really the outcome measure. Are they able to do things that they enjoy the able to continue on with their life. I know outcome measures. Kind of a big puzzle therapies right now in terms of medicine in general is a test that you can give them that shows that if improved And i think we're in the process of developing some of those. Most mark are sensitive enough to know. If there's anything like mike. My goal. When i go to somebody's home or at work with somebody that has had a long standing vision. Problem is often to one task. We can do that you know that they've been unable to that. We can help them start again. I mean and it can be anything. Like i worked with a lady with with macular degeneration which is just. It's not really neural problem. But it has since you know. Some very fundamental function functional problems this this lady love to make this little austrian lady and she likes to make the single needle Holiday cards and so we had to set up a station that provided magnification in light. And really what we did is we just we. We address the specific problem in for her it was magnification lightly and in a stable surface to work with so she could use two hands and we provided that and then she was able to do the task again. And so that's really the outcome measure. That i like the most is can somebody returned to a meaningful tasks again and sometimes one is all we get. And that's that's a pretty good outcome for me. So the last question i have for you is what is the goal of occupational therapists who work with individuals who have vision impairments post stroke in. How do they compare and are build off of neuro ophthalmology goals interventions well. I think it's You here's a good example of how providers of medical providers neuro ophthalmologists work with ot and pt to get the best outcome for patients. We can go so far in the diagnosis and we can identify issues but really we have to work hand in glove because when it comes to function you guys have the trick. Said we don't have. We have the you can put things together. That are gonna work better for patients. I'm yet more time to kind of observe and watch what they're doing what they wanna do. Oftentimes we busy clinics that we have to just run in and run out We don't have you know we can't sit there for five hours or even an hour watching what they're doing and seeing what what they want to be doing so i. This is a good example of interprofessional collaboration right And and how important. That is for every single patient that we see and i i would agree with that. A great deal. I mean i. I'm not comfortable working with somebody you know. Especially if they've got a lot of visual problems on if they've not seen somebody like dr agree i mean dr greaves fantastic. Because she just she understands the therapy component and just the need for people to get better. I mean she's but she is also just a gifted physician in terms of You know figuring out what's wrong in the in the cause and that's those kinds of things are so far above of my my way of thinking. That is just fantastic. When we have her report that suggest this is a problem. Is the problem this problem. And it gives a great place to start in terms of just figuring out how to get person a person back into their lives and it's just a fun relationship awesome. Do you guys have any parting comments or any other paroles. You think you wanna share with us. I i just wanna think doctor degree i. I am especially her descriptions through neural pathways. In that i was taking notes the whole time so like just spend a seminar on news so thank you very much. Well go to the novel website and died your you can have a whole tutorial and all kinds of things Lectures on things The miran court you know the ram is center. Here at the university of utah has just started. A new website called the miran core. It's a clinical ophthalmology resources and education. It's another open resource In there are lectures that we give our residents in visual pathways. And you can listen to these hall. Just a whole lecture that we do for our residents and we've got medical student and basic ophthalmology section so go to the marine corps dot utah dot. Edu and that is a open resource. It's got videos. It's got lectures. It's got grants but it also an end we do. We've started a kind of a rehab component to and So we're hoping that are low vision specialists. And casey you and lisa word. Some of our team here at the man is center. Will work to populate Information for other people across the whole united states and the world This is an open access Website for the whole world as well as our country. That's awesome end on. Part of the american neurologic physical therapy association stroke special interest group We want to just say thank you to both of you or thanking time with us and imparting wisdom thank you very much well and keep up the good works. We have to work together. Yes thank you very much. Thanks a lot.