 It's eight o'clock, so I guess we can get started. So this is the patient support program's day to present cases. So I'm going to present a case of functional vision loss, maybe. So this was a case that was really interesting to me. This was a 48-year-old married Iraqi male. And it was referred from the retina clinic. I just got a call that says, can you come down to clinic? The tech didn't really know anything more other than, well, he's blind. So I went down there without much information. So it's just kind of a little reminder. The more information you can give us, the better prepared we are. But I did glance at the chart, and the patient's acuity was hand movements at one foot, both eyes. He'd come to his appointment with his wife, who really didn't speak English. He spoke pretty well, and he could make himself understood, and he could understand me. So of course, his chief complaint was that he was blind. He was unable to work. He'd exhausted all of his financial resources. He had been denied social security disability, but he was working on an appeal through an attorney. So I was able to gather a little bit of history. He said that he'd worked with the special forces, the US special forces in Iraq, and he had witnessed many terrible, terrible things, as he put it. He was a little bit vague about being in or around some kind of an explosion. I'm sure that was kind of commonplace for what the work he was doing. And he said that he felt like he was losing his brain, and he had had many psychiatric hospitalizations in Iraq. He couldn't remember how many or how long. He also had told me that he had had a stroke when he was in Iraq. He told me that his father had arranged for him to see a very good doctor in Kuwait who told him that he would slowly go blind, and that his vision problems had started about three or four years ago, slowly at first, but over the last year or so, it had really picked up. He said that he used to work in real estate, that he owned quite a bit of real estate, but he had lost everything because of this. So I did ask him about working now. He said he had a job for one day as a custodian. He was kind of embarrassed to tell me that, but that he had lost the job because he couldn't see. And when I asked him about was he in treatment and therapy for his trauma, he said no. Wrong button. So in clinic with this gentleman, we devised a plan. So first of all, he needed some blind skills. Questions that I had, was he eligible for VA benefits? He'd worked with US special forces. Could he attend the training classes at DSBVI at the Division of Services for the Blind and Visually Impaired? This is like an all day, five days a week, up to six months training program. Did he need field mobility training coming out to him? Did he need an occupational therapy visit from our occupational therapist? So these questions are still in my mind. One thing he did say, he said he needed more documentation for his attorney that was working on his Social Security Disability Appeal. So we did give him a copy of the visit for that day. I felt like he definitely needed treatment for the PTSD. And he needed vocational rehabilitation. He needed to be retrained. But really, he needed the blind skills first. So there's kind of hierarchy there. Oops. So I went to work on the plan. He left the clinic, I went to work on the plan. So I researched his eligibility through the VA, low vision services. I had the patient send a copy of what he called his military paper directly to Sharon Jones at the VA in her services. Found out later, he was ineligible because he was actually a contractor with the US Special Forces and not a military personnel. And then I made the urgent referral to DSBVI for training and adjustment services. Talk to them. They said, yes, they'll get right on that. And then I reviewed his chart. And it looked like since he had come to Utah back in about August, July, August of 2017, he'd been seen at the Greenwood Clinic, his primary care. He'd had many problems there. He'd actually been referred up here for vision loss in August. And he had actually been seen in LCSW out there, a therapist who had diagnosed him with PTSD, of course. So he had been getting some treatment. I'm not sure on what kind of a regular basis, but he had been getting some. And I didn't realize it at the time. But when the case managers in the social work services at Greenwood Clinic had been working with him, they had called up and gotten some resources from us for this gentleman. So we had given them transportation options for him. We'd gotten him an eyeglass voucher so we could get his, oops, sorry. Sorry, what am I doing? We'd gotten him an eyeglass voucher so that he could get his glasses that had been prescribed to him. And we had also given them contacts and the process for getting into voc rehab. Through the Moran, I could see where he had come in originally in August of 2017. And the acuity changes from there. I'll show you. So here's the measures of acuity from August of 2017 when he saw Dr. Vincent. January, 2018, there was a referral, well, Dr. Vincent had referred to the neuroophomology. He'd seen Dr. Katz in January. And you can see, you know, there's a pretty sharp decline. We're going from 2100 in the right eye to 2080, correctable, down to 2070 and 2060 to basically counting fingers at two feet and counting fingers at five feet in January. So pretty sharp decline in five months. So in looking at the neuroophomology evaluation, again, he reported the stroke that he had had in Iraq. And some of the tests that were done, the slit lab, look normal, the stereopsis, the fly test, negative. Hey, he had no color perception. The optocrinetic drum was normal, both eyes. Interesting, the finger touching test was abnormal. And we'll touch on this a little bit later. And ERG and a VEP and an MRI and an MLMNOP were all ordered for this gentleman. So when the MRI came back, everything seemed normal. No, nothing to really speak of. VRG looked normal. VEP, maybe some small flash VEP is something maybe happening here. So I put, not knowing really what a normal one looked like, I had Dr. Creel gave me a normal pattern. I'm not sure if the scale is exactly the same they were reporting on two different computers. Something going on there. So Dr. Katz wanted him to see the retina service. Check that out. He also ordered some more tests. The only thing that came back was he was low in vitamin B12, which was addressed later on with his primary care. So Dr. Bernstein saw him. And in the retina exam, everything seemed to be normal. We've got some nice pictures, nice images, nothing remarkable here, right eye, left eye, still nothing. So basically, Dr. Bernstein felt like the post-traumatic stress disorder, really important that that gets treated, leaning towards functional vision loss here. Clearly he needed some help, but everything looked great. So a little bit about functional vision loss. It is the decrease or loss of visual field or acuity, but not organically caused. So about five and a quarter percent of people that come in to outpatient ophthalmology clinics will have some degree, maybe functional vision loss, but interestingly, about half, a little more than half of those, will also have some kind of organic disease going on, this process going on at the same time. Talk about making it complicated, right? So the test to differentiate organic versus non-organic vision loss, the optoconetic drum, which should elicit a nystagmus, proprioception, this is the finger test that Dr. Katz had done. And even people with NLP, they can meet the fingers. This was abnormal in our patient. The visual acuity at different distances, it should improve say from 20 feet to 10 feet, doesn't happen in a non-organic vision loss, bright light, getting a flinch kind of reaction. I thought this was interesting, some kind of like a sleight of hand maybe, saying to the patient, wiggle your fingers, make a fist, do this. And if they're following right along and they're doing this, they're obviously seeing what you're doing. And then also, does the patient avoid the obstacles in the exam room? So let's look at those with our patient. Okay, N was normal, proprioception, finger test, abnormal. The VEP was abnormal to at least some extent. I'm not sure about the other ones, these ones were noted in the chart. So functional vision loss is considered part of what we now call a functional neurological symptom disorder versus a conversion disorder. At the DSM-5, we changed the name of that because a conversion disorder was an old term that Freud made of basically converting psychological symptoms into somatic symptoms. With a functional neurological symptom disorder, the term is more accurate in that it doesn't place all the oneness on the psychological problem. It could be something that we can't determine, we don't know, but it's definitely in their functioning. So this diagnosis of conversion disorder cannot be made by just excluding. We don't know what it is, therefore it must be. You have to prove that the system is working. And so it's not a diagnosis of exclusion. And the symptoms have to be incompatible with the level of functional ability. So a lot of times findings will change based on suggestion. And also if there's some variability from repeated exams, things that kind of should be sending off little flags for you. So some of the predisposing factors for somebody developing a conversion disorder, and I'm gonna call it conversion disorder because the new name is so long and they're used interchangeably still because we haven't adjusted completely to the DSM-5 even though it's been out since 2013. But having an antecedent physical disorder, exposure to other people with either a neurological or conversion disorder, extreme psychosocial stress or trauma, having a history of a childhood physical or sexual abuse for finding this in more and more diseases and disorders as well. It typically hits adolescents and young adults rarely later in life. And it frequently, like many chronic conditions, will coexist with depression and anxiety. So in our patient, definitely an antecedent physical disorder. Don't know about the exposure to other people with neurological or conversion symptoms. Could be very likely having been in Iraq, especially been in a psychiatric unit, things like this. So it's possible, I don't have that history, but it's possible. Definitely, if this should get two checks, extreme psychosocial stress and trauma. We don't know about the childhood history. He doesn't fit the pattern of being an adolescent or young adult at 48. And he definitely has depression and anxiety as well. So looking at the treatments, physical therapy and rehab is very effective for the motor and movement types of symptoms. In fact, this kind of therapy, they really don't want to reinforce that behavior because it's almost like a learned behavior and they don't want to reinforce it. And by asking the patient to do something kind of novel, symptoms aren't present. So Dr. Spee has a wonderful video that I couldn't get downloaded to my computer, but he has a wonderful video of working with a woman with an attack gate and hardly can go forward at all. But when he asked her to walk backwards, she seemed to be able to walk backwards just fine. So these little kind of abilities not matching the symptoms is what I was talking about there. Hypnosis is used, narcosuggestion using narcotics to put them in a suggestive state. Group and individual therapy. Cognitive behavioral therapy is very helpful. Strategic behavioral therapies. Also looking at gaining insight, understanding, coping skills, very important because with this underlying extreme psychosocial stress, in this case of our gentlemen having that PTSD that is still there and he's not been dealing with that very well. And then also the functional electrical stimulation, EMG biofeedback especially with motor problems. What is spectacularly counterproductive is confronting the patients, healing them to snap out of it. So medications are used, but the medications are really treating the comorbid conditions such as the depression or the anxiety. Those do help for that. So these are very somatic symptom disorders are very difficult and we know it. And where is the line from the subconscious, the conversion disorders where it seems to be out of their control to going more towards what used to be called hypochondriasis. Now illness, anxiety disorders coming, being convinced, absolutely convinced that you've got some kind of a very serious condition that just hasn't been diagnosed yet to that fictitious disorder, the malingerers that are trying to get some kind of a benefit. And yes, whenever anybody is applying for disability, the red flags go up and the question comes into our minds. It's not helpful to go there with the patient but it is very difficult to discern what exactly is going on. So going back to our patient, new plan, getting back into treatment for PTSD and working with the LCSW that he'd seen over the Greenwood Clinic, he had made an excellent referral to Rachel Evans at the Utah Healing Center who took his insurance. He has Medicaid, very basic Medicaid but they were able to take his insurance. She herself had been in Iraq. She had very firsthand witnessed some of these things because she could relate to this gentleman very well. And she also had experience in treating veterans with PTSD trauma. So great, great referral. I followed up on the blind skills training of DSBVI. There had been some breakdown in communication. They have tried to reach him. He said he couldn't see the number to return the call. They felt like he wasn't following through. There was a breakdown. He never got the training. So I made sure that the field mobility trainer came out to his home with a cane to train him on mobility so make sure that he was at least safe. And he had also asked me with release of information of course to send a letter regarding our findings here at the Moran to Ms. Evans for his treatment. So after her initial evaluation and reading the letter, Ms. Evans really wanted the conversion disorder to be addressed first. So we made the referral to Dr. Speed. Is he here? I invited him. Thank you, thank you. Who evaluated the gentleman and determined that really a referral for occupational therapy, let's treat the PTSD, hit it hard, concur and let's not wait for sequential kind of treat this, then treat that, let's hit it hard. I followed up on the blind skills. He, yeah, the field services had been out. They are working with him. He still needs more training. He doesn't quite use his cane the way that is most helpful for him. So basically the takeaway points here is whether the disorder is organic or non-organic, the suffering is the same. The patient is suffering just the same whether they, we can explain them or not. They can have a functional vision loss and something else going on at the same time. They do exist together. It's not unusual to have a conversion disorder with PTSD and expectancy effects are very potent. Remember when he said a very good doctor in Kuwait told him he would go blind. The suggestion has been planted. So it's just kind of a caveat. Be careful of your predictions because the patient really latches on to those and can create it for themselves. That works both ways. Being, you know, saying to them, I expect that this was, I expect that this is really going to help you. Is also very potent as well. So, these are my references. Any questions, comments? What do you think? Well, things as you said is you don't confront these patients and say, well, there's nothing wrong with you. You'll be better. But how do we go about, I mean, I know we're gonna be positive. We're gonna say, you know, we're gonna do some training. We're gonna help make this better. We're gonna be included. When they say, well, what's wrong with me? How do you mention that? And that can be tricky. And, you know, I explain it to people of our minds and our bodies are linked. And you can't look at just one or the other. And a lot of times, what you're experiencing is very real, but where it comes from may be different. And I explained to this gentleman, he says, you know, you saw a lot of very dramatic things and, you know, things that you didn't want to see. And so it's the way your body, your mind copes with that is basically, then you don't see those things anymore. So that's kind of how I go about it is kind of like normalizing it in a way that this is a normal way of kind of coping with things that are so terrible that it's impossible to cope with. Dr. Speed, do you have a way that you approach patients with that? Context that I see most patients is because of motor, people get attention. And it's extremely common way, et cetera, et cetera. And the way that I explain motor conversion symptoms is there's a blockage of messages. That sort of A, exposes it in a way that is acceptable and sort of normalizes that to some degree for patients. But B, allows me to say, okay, physical therapy will allow respiration function by starting that, removing that blockage and allowing the messages to get through. And you can use something analogous. I think stress has caused the blockage of the message. It's a little tricky. There's some very difficult, there's some interesting aspects to this particular case. I saw this gentleman last week. One is he's got extremely chronic symptoms now. And that means they're quite behaviorally ingrained in the well. Something I published back in the 90s suggests that there's correlation between the duration of symptoms, how hard it is, and how long it takes to make those symptoms go away. The second thing is Croy talked about the symbolism of the symptoms. So usually that's sort of silly. But in this case, you could sort of perhaps think that he saw these horrific things as a racket sounds like. And so he just doesn't see anything anymore. So that may or may not be of any relevance, but I think it's going to be incredibly challenging for this gentleman to get vision back. But I think that combination of addressing his PTSD and some sort of behavior that we're trying to do down in Schroederhaus may offer some opportunity. But I hope that answers your question about the blockage of the message getting through the affected body, the brain, the vice versa. Contextualizing that to stress. And that's how I explain it to people. People seem to be accepting that. Because the last thing you want to do is make people mad. That's a beautiful explanation. And this gentleman seemed to accept and agree with that idea that he had seen things that he did not want to see. So he was not really upset by that kind of explanation at all. And as of yesterday, he does have an appointment back to work on his PTSD with Ms. Evans, which is good. So we'll hit him with that as well. Well, thank you. Our second presenter, I'll let you figure this out. I'm pleased to introduce, if you don't already know him, Casey Mitchell, who is our occupational therapist that works with the patient support program. He specializes in vision issues. So he'll probably, he also works a lot with the people in the occupational therapist at Schroederhaus. He's taught many of them when he was a professor in the division of occupational therapy. So he will probably end up also working with this patient when it comes to the vision issues as well. But when he's not working with our patients, and our patients love him, by the way, when he's not working with our patients, he is either running rivers or working in his wood shop. Okay, it's kind of fun today. I get to talk about some of the things I get to do with clients, with patients. My favorite thing to do is actually to get into their home or their office. And that way I get to address problems they're having right in the context of the environments they're working in. So this first case study, well, this is just kind of a summary of what I do now. I want you to notice the way that I've put this up here. So I've used a non-embellished font and it's very black on very white. So the clients that I work with, many of the patients I work with have macular degeneration. And so our first things that I often try with them is improving contrast, decreasing the complexity of what they're looking at, adding light. All of these things tend to help them see just a little bit better in terms of their functional vision. A lot of times I see patients in the Moran and one of the things that I find difficult is just going through, trying to get a picture of what they're talking about. Oftentimes a magnifier that works in the clinic here, it's difficult for them to use at home on what they really want to work on. So if I can kind of bypass that and go right to their home, I can look at lighting in their environment. I can look at how they have things set up ergonomically. I can look at safety in their home. Do they have enough lighting to get around with their current vision? And then I can also explore their interests that a lot of times patients as their vision fails, they tend to isolate themselves. And so I can work on things that are meaningful to them. So this first person that I'm illustrating, this is a gentleman who was an attorney that he was still working productively a few hours a day, but he was becoming frustrated because his reading efficiency was not sufficient to keep up with his case load. He was finding that he was cutting his bill, the time that he spent on an actual case, he was cutting the time in half or more to be fair on the client in terms of billing his hours. And so we looked at what he read. And so he would get these court briefs that were printed in, of course, Times New Roman because that's the attorneys, everything has to be in Times New Roman, which is a difficult light. You can see it here. Yeah, let's see if I can get, it's kind of a poor illustration, but you can see the embellishments in the Times New Roman versus the other font that we've got going. And so they would come in about 10 point font and they would have boxes that would be in different colors and in eight point font. And so this was difficult for him to read even with magnification. And this is a gentleman that who had kind of taken it on himself. He had read a lot on low vision and what he needed to do. So I met him in his office and if you can picture his office, it was, there was windows and then he had four foot fluorescent tubes all over the place. And so he really took this idea of more lighting to heart and it kind of backfired on him a little bit. So the magnifiers that he had and he had several, he couldn't really see very well. So what his solution was is he would just increase the magnification. So he had five X magnifiers, four X modified dome magnifiers and it was hard for him to see with the five X magnifier, the greater you increase the magnification, the more field you lose. And so he was really having a hard time. He has his secretary photocopy briefs and this would work to some degree but you would lose a lot of definition in these particular briefs. And this is a gentleman who wasn't really accustomed to using a computer. He was a professional in a paper world. That's one of the things I like to say. But if I hadn't gone to his office, this is the point that I was, I'm trying to make with this, that I wouldn't have been able to see that his primary problem was not the amount of magnification that he had but it was where he was trying to do the work. So he had fluorescent lighting tubes directly above his desk that put a glare in the top of the magnifiers he was working with. And so the solution for him was actually pretty easy. So here's the magnifiers he had. So on the left we have a modified dome magnifier. That's just kind of this long dome that you put right over the sentence. And it worked pretty well but again, that reflection from the lighting that he didn't have installed was creating a glare that he couldn't really see through. And then he had a 5x handheld that he would use all the time but it really over magnified for what he needed. And so the solution that really worked was, so first of all, his goals. He really wanted, this guy was really sharp. He wanted to work as long as he possibly could. I mean this practice is one that he built. His sons, he had two sons that were involved in the practice now and he really felt he was still contributing. But his biggest fear was that he couldn't maintain the efficiency that he needed to be able to add to the practice. And he really didn't want to be a deterrent to his own practice. He didn't want to hurt it. And so he really was kind of in a bind. But one of the things that we found is the glare was the biggest issue. He actually could see quite well with magnification and with the appropriate light. And so one of the things that we did is we placed a binder. He had all these three, I mean three ring binders that he had his case work in. So we put one of these binders on the desk that put an angle on his reading material that got rid of the glare. It reduced or eliminated the glare from the ceiling light. And he was really excited about this. Also the magnifiers he had were sufficient. I mean he had the Forex dome and with less glare on the top of that, he was able to use it. And then we assessed his magnification. And we found, I've got this magnifier down here in the corner, that a different type of magnifier. This is a stand magnifier that's lighted on the inside. It has an LED light on it. That this was sufficient. So we backed his magnification off quite a bit. And he found that with an angled surface, he could read much faster and more efficiently. And so he was pretty excited about this. He was able to read with three acts. And then with a handheld magnifier, we were able to back them off there too. And he was able to read most things like spot reading with a Forex. And then I made him one of these. I'm an amateur woodworker, so I made him a more durable surface to work on. So I made this magnifier stand wide enough to hold the briefs that he uses and made a nicer surface for him to run the magnifiers on. And so he purchased two 3X, one for home, one for his office, two 4X, again, the same thing, one for home, one for office. And then he was pretty excited about the magnifier stand. He was able to read quickly. And he felt that this might keep him in business for a few more years. He was really a fun man to meet. And he just felt how excited he was about his work. And so the ability to stay in that for a little while was important to him. So this next one is somebody that is pretty typical. And we see, so this is an older woman, 85 years old. She really has end stage macular degeneration. And so this particular referral was driven by her daughter. Her daughter was just convinced that she could do more with things that were out there. And so the daughter was there for all visits. And they actually had her home set up pretty well, this little apartment that she was in. They had numbers that she needed to access in really large print, and it took a lot. So we're talking full sheets of paper with two or three numbers on them. I mean, she had dementia, poor memory, no carryover. And so it was really difficult to think about, okay, what can we do for this woman that hasn't already been done? And what can I teach her if there's no carryover to come back to? And so this was something I threw everything I had at her. So basically emptying my bag of tricks. And I couldn't get her to read more than just spot reading. So she could identify a phone number if it were large enough. She had difficulty taking medications. And her biggest complaint was that her apartment was either too hot or too cold. And so I want you to picture an old fashioned thermostat that has the dial. And so what she would typically do is she would just crank the dial one way when she was hot and crank it the other way when it was cold. And so her apartment was extreme. It was either too cold or too hot. And this is the thing that really bothered her the most is that she just couldn't ever get comfortable within her own apartment. Her daughter bought her these electric blankets, but the problem with the electric blankets is they also have a control on it. And so the idea was good, but it just was something that was difficult for her to maintain. So she'd do the same thing with the controller on the electric blanket, make it too hot or turn it off completely. And so we tried a lot of different things. We use contrast to help her see her medications better. So by putting an opposite contrast below the pills, she could see that. The problem is she couldn't remember to use the contrast, the opposite contrast. And so this was something that was difficult. So I trained her daughter with this in hopes that she could reinforce this over many visits. She had a hard time with liquids. And so we talked about the same thing, using opposite color cups to help her see the liquid that she was pouring into. So with milk, use a black cup, coffee, use a white cup, that type of thing. And so we put tactile dots so she could operate her electric blanket control by feel. But again, this would take reinforcement. And so it was good that her daughter was there. And then we modified her thermostat using high print and high contrast. I had a student with me who now works at the Sugarhouse Clinic that came up with a great idea for how to make her thermostat more useful. So here is the thermostat. So the square you see is the small thermostat on the wall and then here's the dial. So my student came up with this idea of painting a toothpick black and gluing it to the thermostat dial. And then we put a big sign with large print, hot or cold. This allowed her to grade the temperature changes. And so, fantastic idea. And it was fun to see her try to use this. And she was able to pull the stick down. By having it on this grade, she could adjust this a little bit easier. So, her daughter was present. So some of these other ideas might work a little bit better with reinforcement over time. But, it really was the change that we made to the thermostat that it was intuitive enough that she could figure it out each time that she used it. And so, of all the things we did, this probably was the most, she enjoyed the most. And so it was a pretty fun outcome to give this person one thing that she could do independently within her apartment. So, these two cases illustrate that a lot of times the solution isn't necessarily a high tech or computerized or something like that. Sometimes it is just a matter of problem solving with the patient. What are ways to improve your ability to interact with your environment? A lot of times, that's one of the reasons I love going into homes or offices with our patients, to help them start this problem solving. So, here's another gentleman that he was a retired financial planner. He had AMD, and he was at the point where he could no longer read very efficiently. And he had a hard time with magnification. So, using like reading glasses, high powered reading glasses or magnifiers with light really was difficult for him to tolerate. And so, he had this amazing set of glasses that went from 3X, 4X, 5X, 6X. It was in this very nice case. It probably cost a lot of money, but it was in a closet that he never used because he couldn't tolerate the magnification. And then he bought this new computer, convinced that he would be able to use it and use the accessibility features to help him accomplish his goals. So, again, we went through the process of what worked and what didn't work. And so, we tried basic magnification first. This is where we learned that he didn't have a very high tolerance for magnification, especially magnification with light. So, he was able to see words, but he complained that he couldn't use it for very long. So, the handheld magnifier at about a 4X magnification was useful for him for spot reading. So, he could read like a pill bottle. He could read an address on an envelope. He could read just a few sentences effectively using this magnifier. But again, he couldn't use it very long to read or to check different things that he wanted to do. We tried his reading glasses again and put him back in the closet because they just didn't work. He could hold up, he could see words, but he just would have, it would cause pain for him to use him for a longer period of time. The next thing we tried is, I tried a portable CCTV, so a close-circuit television with an HD camera. The device that I first exposed him to was about the size of an iPad that you can put over documents and then move it back and forth to read the documents. And this worked quite well, but the difficulty came when he couldn't read a book from his library. He couldn't read, it works really great. This device works really great for flat paper, but difficult when you're reading a book that has a binding. So, this wasn't a great solution for him. We tried an iPad and this worked really well to a point. So, I set him up with a Kindle App on his iPad, increased the font within the Kindle App and reversed the contrast. And for him, this worked really well. He was excited, he had this reading list of things, books that he wanted to read and he read the first book on this list and was really excited to tell me about it. The difficulty came when it came to purchasing a new book. This is where we started teasing out that his computer skills, his basic computer skills were very poor. He had a hard time following the steps of how to purchase a new book on Amazon and then load it on his iPad. Once the book was on his iPad, he could find it and he could bring it up and he enjoyed reading it, but this became kind of a difficult problem to work through. So, this individual has, he was paying somebody to come in two or three times a week and help him with mail, help him with correspondence and this became one of her jobs, was to keep him stocked with books that he was interested in reading. And this was something that took some of the frustration out of it, to have help with this particular part of the task so he could just enjoy the reading. This was, when I saw him, this was about the time that the dots were coming out. Now we probably could just set it up on like an Amazon dot and then have him order it through verbal commands. And so this is, as technology improves, especially technology over the shelf, I mean off the shelf technology improves, we can utilize that to help people skip these steps sometimes. So, the thing that was probably the most frustrating for him was his computer and I enabled the Windows accessibility features so he could see print on his screen. But this is where we further learned that he was a professional in a paper world, as I said earlier. And he admitted that he really did very little on a computer. His secretary would often do things for him on the computer or set something up for him. And so when we talk just a little bit more candid about his personal computer skills, we realize that he really didn't have any of them. And so this was less of a low vision concern and more of he needed to learn how to use the computer, which is a longer term process. And so we got him so we could do a few things on the computer like he loved to check out movie times at his local movie theater. And so we made it so he could find that particular website, blow it up and then look through the movie choices. But that was difficult. We helped him get into Word and set fonts bigger. But again, somebody would have to set this up for him. He really had a hard time navigating between elements of this. And this is where we reintroduced the idea of a CCTV. So I brought a demo to his house of a larger CCTV. So here's an example of a CCTV. So you basically have a computer screen with a camera down and then there's a table below that you can actually move written material or pictures or anything like that below the screen to look at. And once we'd gone through this whole process, he liked this piece of it. He could take books from his library. He could take correspondence. He could take pictures and put it below this device and actually see them. And so we had to wear him down a little bit on the computer and then present a device that worked well for him. So it often is a process. People have an idea of what they want to be able to do and sometimes their method in getting there is not as efficient as it could be. So eventually this is what he went with and he enjoyed it. Realizing that his computer skills would take time to, and that was the question he started asking. Is it worth it for me to learn how to use a computer? And I kept encouraging him to stay with it but I think this is what he's gonna do most of his reading through this and the basic iPad. So my job is to work with patients and help find solutions for improving their function with the vision they have. And so pretty fun job. Most of the time I go out and meet very nice people and we come up with, my goal is always to come up with one thing that we can do better with them. Sometimes we get a whole bunch of them but oftentimes with the example of a woman with a dementia we left with one thing that really did it improve her function. So any questions? Go ahead. Are you able to work with any of the people that are a little bit outside the Salt Lake City area? How would that work? I'm going to Morgan today. So as long as it's not too far I think I've gone to Evanston once for one of your clients. But yeah, given enough notice if you work with Lisa now that presents some interesting things if I go to a different state that we have to book a day out and then I don't have licenses, an OT license anywhere but Utah. And so we have to go there just to provide the service we really can't bill for it. Something we're definitely willing to look at. Yeah, so I look at Casey's schedule so I don't have him running from Provo to Ogden and then back to say Spanish fork in one day. So I try to kind of look at that and I'm working with the schedulers and also kind of planning that. So he's hitting things in sequential order without running all over. You had a question. Any tricks of work with patients with immunopsies? Yes, my background's in neuro rehab. And so my main job is I work in a neuro outpatient clinic and so I'm becoming more comfortable with neuro related vision. And so, yes, definitely. What are you doing? What kind of things do you do? Yeah. I kind of take kind of an approach that we've got to get them comfortable scanning to that blind spot. We've got to get them comfortable. Now, if there's some neglect in there it becomes even more difficult but I love to train the family and I love to just do lots of repetitions getting them to look to this side whatever the effected side is. And a lot of times I'll walk behind them. I'll have a family member walk in front and I will just set up a set of cues where they're looking at the person in front and then they have to look at me to the side and then front to the side. And I'll try to set this up on a cadence where we're programming them to look every few steps to that side. Because if we can teach them that scanning they can become quite functional. If we can't get them over the burden of that side exists then it's still difficult. And I'm looking into technologies that are out there that might help. There's a couple that are kind of on the cusp that there's one device that will actually say, they wear an earpiece and it scans. Right now it's for people with macular degeneration. So it will scan like a central field and help them with facial recognition and things like that. If I can get with those guys to help them, even an audible thing that says look right, look right, look right, or look left, look left. I think something like that would be helpful but doesn't exist just yet, but. Any success with prism glasses, do you ever? I think if you can teach people what their vision, how to use the prism glasses effectively, I think people give up on prism glasses too quickly. I'd like to talk to them about how it's almost like a rear view mirror to the side. They've got to keep that spot in the central vision and then when they look up or look down it gives them a preview of what's over there. So they can almost use their eye movement instead of head movement. So for some people that does work better but the clients that I've worked with when you're just shifting their vision with prism, they tend to get used to it. And so it's like there's a short-term gain but their brain is too smart for it. So I haven't seen like a lot, a more effect beyond that. Now I'm sure there are cases that I haven't worked with longer term than it has effected but. Definitely it's in the bag of tricks. It's just whatever tends to work for the client. So I love it when they've been seen by somebody and have the prisms in is it gives us another thing to work with. Any other questions? One other thing on Hemianopsia, a lot of times we focus a lot on their functional movement but I like to also work with them on reading and help them figure out the scanning. So we'll put like a visual anchor and a line guide and then that gives them a lot of repetitions to move to that side as they read that full sentence. So I think it's essential to look at more than just mobility but also to look at reading and close tasks as well. So. Thank you. Thank you.