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      An Audiovisual 3D-Immersive Stimulation Program in Hemianopia Using a Connected Device


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          Patient: Male, 15-year-old (7-months-old in at diagnosis)

          Final Diagnosis: Homonymous hemianopia

          Symptoms: Visual field defect

          Medication: —

          Clinical Procedure: Audiovisual stimulation at 15-years-old

          Specialty: Ophthalmology • Rehabilitation


          Unusual or unexpected effect of treatment


          Homonymous hemianopia is a loss of conscious vision in one hemifield, strongly affecting everyday life. Audiovisual stimulation programs improve visual perception in the blind hemifield; however, they use large equipment operated in clinical settings. Such treatments require frequent visits at the clinic, hampering the patient’s adherence and compliance. In one hemianopia patient, we tested a 4-week dynamic audiovisual rehabilitation program in the stand-alone, remotely controlled, virtual-reality, head-mounted display Oculus Go and measured the effect on visual perception.

          Case Report:

          A 15-year-old Caucasian male was diagnosed with a right homonymous hemianopia with splitting of central fixation after a traumatic occipital contusion at age 7 months. Visual assessment showed impaired binocular contrast sensitivity and retinal sensitivity. Fixation stability and visual fields were strongly affected. After a 4-week audiovisual rehabilitation program, including 3 hours 20 minutes of stimulation, the contrast sensitivity, fixation stability, and paracentral visual perception were significantly enhanced, improving quality of life.


          This pioneering work reports the use of virtual-reality in a head-mounted display to provide an audiovisual stimulation protocol for low-vision rehabilitation in a hemianopia patient. Real-time data recording and remote control of the stimulation program demonstrate that such rehabilitation treatment can be performed by the patient at home without interruption of care, decreasing the burden of disease. Beneficial effects on visual function were measured according to clinical guidelines of low-vision assessment. Improvement in visual function and quality of life challenge the prevailing belief that post-acute vision loss is both permanent and unchangeable.

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          Most cited references 45

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          Determinants of multisensory integration in superior colliculus neurons. I. Temporal factors.

          One of the most impressive features of the central nervous system is its ability to process information from a variety of stimuli to produce an integrated, comprehensive representation of the external world. In the present study, the temporal disparity among combinations of different sensory stimuli was shown to be a critical factor influencing the integration of multisensory stimuli by superior colliculus neurons. Several temporal principles that govern multisensory integration were revealed: (1) maximal levels of response enhancement were generated by overlapping the peak discharge periods evoked by each modality; (2) the magnitude of this enhancement decayed monotonically to zero as the peak discharge periods became progressively more temporally disparate; (3) with further increases in temporal disparity, the same stimulus combinations that previously produced enhancement could often produce depression; and (4) these kinds of interactions could frequently be predicted from the discharge trains initiated by each stimulus alone. Since multisensory superior colliculus neurons project to premotor areas of the brain stem and spinal cord that control the orientation of the receptor organs (eyes, pinnae, head), they are believed to influence attentive and orientation behaviors. Therefore, it is likely that the temporal relationships of different environmental stimuli that control the activity of these neurons are also a powerful determinant of superior colliculus-mediated attentive and orientation behaviors.
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            Perceptual learning in Vision Research.

             Dov Sagi (2011)
            Reports published in Vision Research during the late years of the 20th century described surprising effects of long-term sensitivity improvement with some basic visual tasks as a result of training. These improvements, found in adult human observers, were highly specific to simple visual features, such as location in the visual field, spatial-frequency, local and global orientation, and in some cases even the eye of origin. The results were interpreted as arising from the plasticity of sensory brain regions that display those features of specificity within their constituting neuronal subpopulations. A new view of the visual cortex has emerged, according to which a degree of plasticity is retained at adult age, allowing flexibility in acquiring new visual skills when the need arises. Although this "sensory plasticity" interpretation is often questioned, it is commonly believed that learning has access to detailed low-level visual representations residing within the visual cortex. More recent studies during the last decade revealed the conditions needed for learning and the conditions under which learning can be generalized across stimuli and tasks. The results are consistent with an account of perceptual learning according to which visual processing is remodeled by the brain, utilizing sensory information acquired during task performance. The stability of the visual system is viewed as an adaptation to a stable environment and instances of perceptual learning as a reaction of the brain to abrupt changes in the environment. Training on a restricted stimulus set may lead to perceptual overfitting and over-specificity. The systemic methodology developed for perceptual learning, and the accumulated knowledge, allows us to explore issues related to learning and memory in general, such as learning rules, reinforcement, memory consolidation, and neural rehabilitation. A persistent open question is the neuro-anatomical substrate underlying these learning effects. Copyright © 2010 Elsevier Ltd. All rights reserved.
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              Enhancement of visual perception by crossmodal visuo-auditory interaction.

              Neurophysiological studies have shown in animals that a sudden sound enhanced perceptual processing of subsequent visual stimuli. In the present study, we explored the possibility that such enhancement also exists in humans and can be explained through crossmodal integration effects, whereby the interaction occurs at the level of bimodal neurons. Subjects were required to detect visual stimuli in a unimodal visual condition or in crossmodal audio-visual conditions. The spatial and the temporal proximity of multisensory stimuli were systematically varied. An enhancement of the perceptual sensitivity (d') for luminance detection was found when the audiovisual stimuli followed a rather clear spatial and temporal rule, governing multisensory integration at the neuronal level.

                Author and article information

                Am J Case Rep
                Am J Case Rep
                The American Journal of Case Reports
                International Scientific Literature, Inc.
                09 June 2021
                : 22
                : e931079-1-e931079-6
                [1 ]Low-Vision Service, Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
                [2 ]Donald K. Johnson Eye Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
                [3 ]Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
                [4 ]Hospital for Sick Children, Toronto, ON, Canada
                [5 ]Department of Cell and System Biology, University of Toronto, Toronto, ON, Canada
                [6 ]Department of Laboratory of Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
                Author notes
                Corresponding Author: Michael Reber, e-mail: michael.reber@ 123456uhnresearch.ca

                Authors’ Contribution:


                Study Design


                Data Collection


                Statistical Analysis


                Data Interpretation


                Manuscript Preparation


                Literature Search


                Funds Collection


                Samuel N. Markowitz and Michael Reber are co-senior authors

                Conflict of interest: None declared

                Source of support: Start-up grant 2018, Donald K. Johnson Eye Institute, Krembil Research Institute, University Health Network

                © Am J Case Rep, 2021

                This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International ( CC BY-NC-ND 4.0)



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