1/4/2021

1

Assessing andtreating Visual

deficits

ANGIE REIMER OTD, MOT, OTR, CBIST

AREIMER@NEURORECOVERY.NET

Eye muscles

Lateral Rectus

Medial Rectus

Inferior Rectus

Superior Rectus

Superior Oblique

Inferior Oblique

Control of eye movementsH T T P S : / / WWW. N E U R OA N A T O MY . C A / MO D U LE S / E Y E MO V E ME N T / S TO R Y _ H T ML 5 . H T ML

1

2

3

1/4/2021

2

Eye

movements

Pursuits: Ability to track objects with eyes, allow smooth, continuous viewing of a

moving object

Saccades: Quick, simultaneous movement of

both eyes between two or more targets of fixation in the same direction

Convergence: Eyes aligning together to focus on one object (Near point convergence of 2-4 inches is WFL)

Accommodation: Ability of the eye to change its focus from distance to near sight

(not tested over age 40)

Eye teaming disorders

Inability to fuse information from the right and left eyes to form one image

Most common problem post-stroke

Symptoms:

Double vision

Blurred vision

Headache

Difficulty reading

Eye strain

THE VISUAL SCREEN

4

5

6

1/4/2021

3

Screening smooth pursuits

Patient positioned facing therapist

Patient to follow an object 12 inches away from face with both eyes

without moving head

Eye movements should be smooth and symmetrical, note if the

patient has difficulty attending, loses the target, blinks often, reports double vision or light headedness/dizziness.

7

8

9

1/4/2021

4

Confrontation testing

Screen of available visual fields

Can be completed acutely at bedside

Patient is positioned facing the therapist with one eye occluded

Therapist uses a dowel with a contrasting color on the end to assess visual fields- with

the target about 16 inches from the head assess from all directions – completed on each eye

Screening Saccades

Patient sitting facing the therapist

Hold 2 tongue depressors (one with a red dot and one

with a green dot) 16 inches in front of patient’s face and about 4 inches from midline.

Give the directions “Look back and forth between these two objects quickly” – have patient complete 10 fixations

Adults with no visual impairment will complete perfectly. Watch for consistently under or

overshooting the targets

Assessing eye

teaming

Position patient sitting facing therapist

Slowly bring an object closer to the

patient at eye level and midline. Ask

patient to keep both eyes on object

and report when they see two. Take

note of the distance from face and

continue to move an inch or two closer

to the face before moving the item

away asking them to watch with both

eyes and report when they see one.

Watch how the eyes move together or if

they stop working together- one may

drift

Double vision should occur at 2-4 inches

and return to single vision at 4-6 inches

10

11

12

1/4/2021

5

TREATMENT OF VISUAL DEFICITS

Intervention

for Hemianopsia

Compensatory Treatment

Learning compensatory strategies

of purposefully scanning the blind

hemifield

Train for large scale eye

movements toward the visual cut

Habituation is key…Do it until it is a

habit to check that visual field

Line Bisection Test

13

14

15

1/4/2021

6

Adding a visual anchor

Games

requiring scanning

Dominoes

Solitaire

Sequence

Memory

Connect 4

Attach video games or computer software to a projector for larger field of view

16

17

18

1/4/2021

7

Intervention for Hemianopsia

Prisms – shift the peripheral image toward the central area of the retina

Require a referral to optometrist/opthamologist

Ground into lenses or sitck on (Fresnel)

Difficult to get used to- may cause double vision or distortion of images

Significant improvement with tabletop activities noted, but no difference in ADLs or mobility (Rossi et al, 1990)

Intervention for pursuits

Line tangles

Connect the dots

Mazes

Flashlight tag

Object tracking (Ex: Ball on a string)

Flashlight spelling –

Use a laser or flashlight to form letters on a wall in a dark room-have patient try to identify or describe the letters

Racetrack task-

Draw a racetrack on the wall (whiteboard etc.) – hold laser or flashlight and move around the track like a car. Have the patient tell you if it leaves the track

Intervention for Saccades

Hart chart

http://semovisioncare.com/Pt%20Forms/Pt%20education/Hart%20Chart.pdf

http://hartchartdecoding.com/index.html#home_page

Letter tracking

Word searches

Reading tasks

19

20

21

1/4/2021

8

Treatment of Diplopia

Full vision Occlusion:

“pirate patch”

Loss of peripheral vision

Decreased depth perception

Increased eye strain

Needs to be last resort- NOT for long term use

MUST ALTERNATE OCCLUSION

Alternate every other hour

Continue with ocular ROM exercises

Treatment of Diplopia

Partial vision occlusion:

Add tape to patient’s glasses (or fake glasses)

Can be used for longer periods of time without

risk of weakness in one eye

Central occlusion:

1 cm round patch (translucent) placed directly in line of sight

Nasal occlusion:

Place translucent tape over nasal field of one (or both) eyes

Treatment of Diplopia

Prisms

Can be ground in (permanent) or press on (temporary)

Require assessment by eye professional

Eye exercises

Pencil pushups

https://careguides-videos.med.umich.edu/media/Pencil+Pushups/1_h86uobxb/88922621

Brock string

https://careguides-videos.med.umich.edu/media/Brock+String/1_a8t3ixzy/20345631

Barrel cards

22

23

24

1/4/2021

9

Brock String

Set Up:

1. Make a loop at the end of both of the white string.

2. Affix one end of the string to a doorknob.

3. Position the far bead near the end of the string closer to the doorknob. This is the far fixation bead.

4. Place the middle fixation bead about 2 ft -5 ft from you.

5. Place the near fixation bead about 6 inches from your nose.

6. Stand directly in front of the doorknob facing it. Put the loop around your finger and hold the white string under your nose like a mustache,

7. Hold the cord up to the bridge of your nose so that the cord is stretched tight between your nose and the doorknob.

Brock string directions

1. Look at the near fixation bead. Keep this bead single as you look directly at it. If the near bead is double this indicates an eye teaming problem. if this occurs, move the near bead closer or further away until you see it as a single bead. The near bead should be moved closer and closer as the task becomes easier.

2. Eventually, the near bead should be only one inch from the bridge of your nose.

3. As you look at the near fixation bead you should see two strings, each of which appears to come from your eyes. if your fixation of the bead is accurate, the two strings should appear to meet exactly at the bead forming an "X". As the bead is moved into one inch from your nose, the two strings should appear to meet exactly at the bead forming a "V".

4. Shift your eyes to the middle fixation bead and then to the far fixation bead and repeat. if your fixation of the far bead is accurate, the two strings should appear to meet exactly at the bead forming a "V".

5. Change the location of the fixation beads and again repeat.

Vision therapy – office based

Individually prescribed HEP

Monitored by optometrist

Administered by a specially trained therapist under supervision of

optometrist

Requires multiple visits and activities (several weeks to months)

25

26

27

1/4/2021

10

VOR – Vestibulo-Ocular Reflex

Gaze stabilizing reflex

stabilizes gaze during head movements by producing an eye movement in the direction opposite of the head movement

Since slight head movement is constant VOR is critical for stabilizing vision

Testing VOR-

Visual fixation during head turns (check vertical and horizontal)– if this illicits symptoms further evaluation needed by VRT

Deficits require vestibular therapy by a certified professional

Vision Specialists

Ophthalmology

Attends medical school with residency in ophthalmology

Looks at medical aspects

Eye health: Medications/surgery

Acuity

Neuro ophthalmologist

Additional fellowship in neuro ophthalmology

Addresses damage to optic nerve, eyelid malfunction, eye movement

Vision Specialists

Optometry

Attends optometry school (4 years)

Looks at functional vision

Neuro optometry

Additional residency in neuro optometry

Addresses visual efficiency, tracking, teaming, focus and vision therapy

28

29

30

1/4/2021

11

Resources for vision professionals

Neuro-optometric Rehabilitation Association (NORA)

https://noravisionrehab.org/

International Academy of Low Vision Specialists

https://www.ialvs.com/

Visual Perception

Visual Perception

-THE BRAIN INTERPRETING/MAKING SENSE OF WHAT YOU SEE

-COMMON ASSESSMENTS LOOK ONLY AT 2 DIMENSIONAL TASKS

-CARRY OVER INTO DAILY LIFE IS NOT CLEAR

31

32

33

1/4/2021

12

Common

assessments

Beery-VMI

Ages 2 – 99:11

Test of visual perceptual skills (TVPS)

Ages 5 – 21

Motor Free Visual Perceptual Test (MVPT-4)

Ages 4 – 80+

NO motor skills required

Hooper Visual Organization test

Ages 5+

MVPT Examples

Visual Perceptual Skills Visual closure

ability to identify a form or object from an incomplete presentation

Figure Ground

Ability to distinguish objects from a background

Visual Memory

ability to remember what is seen for immediate recall

Form Consistency

ability to accurately recognize and understand that an object remains the same despite changes in size, direction, orientation, color, texture or context

Visual Discrimination

ability to identify differences and similarities between shapes, symbols, objects and patterns by their individual characteristics

Visual Spatial

ability to understand the position of two or more objects in relation to oneself and in relation to each other

Visual Motor Integration

Ability to make sense of visual information and use appropriately for a motor task

34

35

36

1/4/2021

13

Visual perceptual Resources

Visual Discrimination

http://www.highlightskids.com/double-check

http://www.spotthedifference.com/explorer.asp

Figure-ground

http://www.highlightskids.com/hidden-pictures

http://www.pogo.com/hidden-objectgames?pageSection=fp_categorybar_puzzle.hidden

http://www.scholastic.com/parents/play/games/

Visual Closure

https://eyecanlearn.com/perception/closure/

Visual motor

http://krokotak.com/2013/01/hand-and-eye-coordination/

Questions?

37

38