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Occupational Therapy and

Vision
Jilianne Normandy
Vision
3 basic functions:

- Visual acuity
- Visual field
- Oculomotor control

(Berger, Kaldenberg, Selmane, & Carlo, 2016)


Extraocular Muscles Patterns of movements:

- medial rectus: adducts and rotates eyes inward (CN III)

-lateral rectus: abducts and rotates eyes outward (CN VI)

- superior rectus: elevation and intorsion to move eyes


upward (CN III)

- inferior rectus: depression and extorsion to move eyes


downward (CN III)

- superior oblique: depression and intorsion to rotate


eyes downward and outward (CN IV)

- inferior oblique: elevation and extorsion to rotate the


eye upward and outward (CN III)

(Gillen, 2009)
Deficits in the visual field produced by lesions at
various points in the visual pathway

(Gillen, 2009)
Visual impairments
- increased risk for falls
- May be limited in mobility
- May have significant reading deficits
- May display a higher prevalence of depression
- Inability to recognize faces
- Getting lost
- Driving problems
- Difficulties with ADLs
- Poor rehab outcome

(Berger, Kaldenberg, Selmane, & Carlo, 2016)


Visual Processing
- Changes in vision may occur following a
neurological event
- TBI, stroke, multiple sclerosis, Parkinson’s
disease, cerebral palsy, epilepsy, etc
- Other causes: aging of ocular anatomy, diabetic
retinopathy, cataracts
- Common visual impairments include: visual field
deficits, loss of ocular alignment, or control,
diplopia, unilateral visual neglect, and changes in
visual acuity. (Berger, Kaldenberg, Selmane, &
Carlo, 2016)
Visual Screening
Specific visuomotor abilities that should be assessed include:

- Fixation: the ability to steadily and accurately gaze at an object of regard


- Pursuits: the ability to smoothly and accurately track or follow a moving object
- Saccades: the ability to quickly and accurately look or scan from one object to another
- Accommodation: the ability to accurately focus on an object of regard, sustain focusing
of the eyes, and change focusing when looking at different distances
- Vergence: the ability to accurately aim the eyes at an object of regard and to track an
object as it moves toward and away from the person
Visual Screening
The therapist should look for the following:

- Facial expressions, head turning or slanting, squinting


- Fatigue, frustration, complaints of headache, etc
- Complaints of losing one’s place when reading
- Quality of eye movements
- Smooth vs. jerky movements
- Eyes missing or losing the targets
- Over- and undershooting
Visual Screening Tools
Visual Screening
Perception

- Cover test: focus on a central target, with one eye covered to see if uncovered eye can fixate
- Saccades test: alternate fixating between two objects at 6 inches apart and 16 inches from
bridge of nose to observe eye’s ability to rapidly and smoothly move between objects
- Tracking test: moving a pen light or target through 9 gaze positions to observe speed,
coordination, and ROM of eyes.
- H and O pattern
- Convergence test: moving a pen light toward the bridge of nose until it reaches point of
convergence, usually 3 inches from bridge of nose, to observe the eye’s ability to converge
- Target and fixation: patient visually locates and fixates on a target
Visual Screening
Perception

- Visual fields:
- Peripheral vision: have patient say “now” when they first see your glove on the left and
right side, as well as superiorly.
- Confrontation field test
- Adding fingers together
- Examiner will present one or two fingers randomly for 1 second duration to each
quadrant of the visual fields. The fingers are presented 18 inches away from the
client and at approx 20 degrees from the line of fixation
Visual Screening
Perception

- Hirschberg test:
- A screening test to assess whether a
person has strabismus
- Strabismus: ocular misalignment. A
visible turn of one eye and may result
in double vision. The person is unable
to keep the eye straight with the
power of fusion
Visual Screening
Visual attention and scanning evaluations

- Letter cancellation: with single letters arranged in a


row, patient is asked to cross out a target letter.
Patients with unilateral visual neglect will avoid
scanning one side of the page, while asymmetrical
performance indicates problems with visual
attention
- Line bisection test: patient is asked to draw a line
through the center of two horizontal lines. Patients
with unilateral visual neglect will draw the line
ipsilateral to their lesion
Vision Screening
Nystagmus and the null point

- Nystagmus: involuntary, rhythmic movement of the eyes


- Nystagmus severity can vary upon direction of gaze, the eyes oscillate more when looking in certain
directions
- The gaze position of least eye movement is the “null point” and tends to be where vision is best
- Tilting or turning the head into this direction where the movements are least can optimize vision
- To find the null point:
- Hold a pen or small bright object in front of the eyes
- Ask the patient to hold his/her head still, and follow the object as it is moved from side to side, and up and down
- Watch for any increase or decrease in the nystagmus
Vision Questions
- Always ask if they wear glasses, and have them wear them if they can!
- Double vision
- Blurriness
- Nature of symptoms
- Constant vs. intermittent
- Changes from day to day
- Other symptoms that could exacerbate the condition and/or symptoms
- Barriers to learning
Treatments
Environment and compensatory strategies
- ALWAYS make sure the patient has the best corrected vision (ex:wearing correct glasses)
- Well lit room with no glare
- Limit time doing visual tasks that take concentration
- Taking frequent breaks
- Increase illumination, contrast, or print size
- Clutter-free, unless the patient is working on more complex visual tasks
- Quiet, unless the patient is working on more complex tasks
- Determine whether the patient should be seated, standing, or performing a task that involves
walking
Lighting
(Green, Barstow, & Vogtle, 2018)

- 33% of all patients admitted at least one area of visual concern that interfered with ADL performance
- 55% of patients diagnosed with a CVA demonstrated visual concerns
- Out of 326 people with CVA’s: 68% had eye alignment or movement impairment, 49% had visual field
impairment, 27% had low vision, and 21% had perceptual difficulties
- Procedure
- Participant A: Participant B:
- Day 1: 18:58 min, FIM:3 - Day 1: 22:42 min, FIM:3
- Day 2: 10:29 min, FIM:4 - Day 2: 9:55 min, FIM:4
- Day 3: 14:50 min, FIM:4 - Day 3: 12:58, FIM:4
- Day 4: 8:44 min, FIM:5 - Day 4: 11:34 min, FIM:5
- Timed data and FIM scores indicated that increased lighting sources resulted in less time at a higher
functional level for grooming. This result suggests that increasing the amount of light may improved
performance of the occupation of grooming
- Findings:
- Visual function should be routinely assessed in acute care settings
- Lighting preferences (type position, power) should be considered as an adjunct to therapeutic intervention
- OT’s should consider lighting as a visual cue for visual-spatial neglect and visual field deficits
Visual Field Deficits
Functional training

- Awareness of blind side


- Teaching to visual scan to a prism placed in area of
vision loss

Compensatory strategies

- Use of markers, anchors to identify patient’s place


through touch
- Modify the task or environment to maximize the
patient’s ability to participate
- Educate the patient about the impairment

Grading the tasks, activity analysis

- Density: low density to high density


- Structure: task (organized → random)
- Speed: start with slow, deliberate movement, slowly
increase speed
Visual field deficits/ visual
inattention and neglect
Techniques to teach the patient:

- Visual search strategies, including left-to-right for reading. Start in at the far end of the affected side,
use a circular pattern for larger scanning activities
- Large-scale eye movements for mobility and scanning in the environment
- Lighthouse
- Small-scale eye movements for reading and near tasks
- Increased head turns, especially into the affected area
Visual processing component skills training
Visual scanning or eccentric viewing strategies

- Scanning is an effective intervention to improve search skills when measured with a functional search
task
- Training strategies skills such as sweeping eye movements, timed visual tracking activities, scanning,
tracing exercises, repetitive writing exercises can help with reading and writing tasks for persons with
visual field deficits
- Scanning activities:
- word search
- connect the dots
- Reading
- Mazes
- Crossword puzzles
- Scavenger hunt
- Walk down a hallway and identify what is on the wall (or place sticky note with numbers or
letters on them)
Saccades impairment
Basic saccade exercise Alternate saccadic exercise

- Use two targets and an eye patch or - Use columns of numbers or letter on paper
occluder. Ask the patient to look back and and an eye patch or occluder
forth between the two targets - Have patient read the two columns left to
- Start slowly, holding the gaze for several right, moving from top to bottom
seconds, and move back and forth - As needed, have the patient use fingers or
between targets. As patient improves, other anchors, progressing to no anchors
gradually increase speed - Use stopwatch to document progress
- Move targets so patient moves gaze into - Change speed using a metronome
different directions of view (have the - Start with two columns, then increase the
targets as if at the end points of a + sign number of columns
and an X; move side to side, up and down,
diagonal
Decreased oculomotor control/diplopia
Functional training Other suggestions

- Training tracking exercises or oculomotor - Emphasize accuracy then work on speed


skill development - Eliminate head movements during pursuit and
- Partial occlusion/ opaque eye patches saccadic eye movements for activities that can
- Eye exercises be accomplished without head movement
- Pencil push ups, Lateral gaze, - Increase complexity of the tasks to work toward
near/far, scanning activities automatic eye movements
- Metronome, balance board, cognitive
Progression task that incorporates eye movements
- Start with only one eye at a time (cover other
- Progress from easiest direction for person to eye with patch) until both eyes are doing the
move his or her eyes to the most difficult exercise equally
- Progress from horizontal tracking, vertical
tracking, and circular tracking
- For saccades, work from large to small eye
movements
- For pursuits, progress from small to large eye
movements
Oculomotor exercises
Useful for: pursuits, decreased oculomotor
control, diplopia

Exercises:

- Using a target and an eye patch or


occluder, move the target slowly back and
forth several times into all directions of
view (ex: make a “+” and an “X”)
- Pencil push ups
- Scanning
References
Berger, S., Kaldenberg, J., Selmane, R., & Carlo, S. (2016). Effectiveness of interventions to address visual and visual-perceptual impairments
to improve occupational performance in adults with traumatic brain injury: A systematic review. The American Journal of Occupational
Therapy, 70(3), 70031800010p1-70031800010p7.

Chung, A., Wiemer, H., Richards, C, Richman, S. (2017). Visual dysfunction: Occupational therapy. Cinahl Information Systems, 1-18.

Gillen, G. (2009). Managing visuospatial impairments to optimize function. Cognitive and Perceptual Rehabilitation: Optimizing Function (45-
65). St. Louis, Missouri: Mosby Elsevier.

Gillen, G., Nilsen, D. M., Attridge, J., Banakos, E., et. al. (2015). Effectiveness of interventions to improve occupational performance of people
with cognitive impairments after stroke: An evidence-based review. The American Journal of Occupational Therapy, 69(1), 6901180040p1-
6901180040p9.

Green, M., Barstow, B., & Vogtle, L. (2018). Lighting as a compensatory strategy for acquired visual deficits after stroke: Two case reports. The
American Journal of Occupational Therapy, 72(2), 7202210010p1-7202210010p6.

Wagener, S. G., Anheluk, M., Arulanantham, C., & Scheiman, M. (2013). Vision assessment and intervention. Mild TBI Rehabilitation Toolkit,
97-146.

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