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Binocular Coordination requires effective…
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Binocular Dysfunctions due to TBI may results in…
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- Smooth pursuits/tracking
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- Inadequate gaze stabilization and bifocal fusion
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- VOR
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- Poor eye-head dissociations
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- Saccades
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- Strabismus
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- Convergence
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- Diplopia with or without changes in gaze
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- Divergence
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- Suppression (brains response to diplopia)
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- Stereopsis/Spatial localization
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- Vergence Insufficiencies (usually convergence)
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- Focal and Ambient Visual Processing (Physiological diplopia )
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- Accommodative Insufficiency (CN III)
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- Visual fatigue due to poor oculomotor control
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Signs or symptoms following a blow, hit, bump, jolt or any identified trauma to the head that persist >4 weeks include:
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Dizziness
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Slurred Speech
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Headaches
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Poor judgement & decision making
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Blurred Vision
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Memory problems
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Nausea
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Sleep disorders
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Vomiting
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Emotional instability
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Easily irritable or changes in personality -> “I feel crazy.”
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Rigid and stiff body movement
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Changes in speech: stammering, difficulty with cohesive thoughts
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Avoids stimuli: wears sunglasses, “I cannot go to the grocery store anymore.”
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Forgetful & unable to concentrate
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Avoidant behaviors (Self-isolates from others, decreased socialization; Stops participating in hobbies & extracurriculars)
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Needle in a haystack: Visual diagnoses often look like other diagnoses
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Be careful of jumping to conclusions.
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Certain diagnoses are more well-known by those who have influence (e.g., ADHD)
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I have a vision problem?
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Fatigued, stressed.
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Missing out on experiences.
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Stigma
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Self advocates, over explainers.
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Adapters – Not always beneficial long term.
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Occupational and physical therapy understand movement and function
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Advanced trainings or certifications can overlap with the same skill set as vision therapists
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OT collaborates with neuro-optometrists for guidance for vision-based therapy
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Insurance often does not cover Vision Therapy services!!!!!!!!!!
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Must perform adequate and efficient visual and vestibular screenings during the evaluation process
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Pediatric-based nature
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Many individuals with Mild TBI push themselves beyond a point of recovery, which often can leave them “helpless” for hours or even days.
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“Functional Activities Log”- Tracking specific activities that are perceived triggers for onset of symptoms; E.g. computer or screen-time, reading, scanning for grocery items, eating in a crowded restaurant, riding as a passenger in the car, etc.); Stigma, metal health concerns
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Goal: reduce onset of symptoms by participating in short spurts of activity over a longer period of time
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1. Establish a baseline: Determine length of time an activity occurred resulting in onset of symptoms
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2. Establish the most effective strategy for reducing symptoms:E.g. meditation, laying down in a dark and quiet environment, covering eyes with palm of hands with slight application of pressure
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3. Establish a “Pacing” Plan: Terminating or pausing an activity prior to onset of symptoms; then resuming activity after symptoms subside
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- If onset of symptoms occur at 20 minutes, then pausing, terminating, and switching to a different task should happen prior to 20 minutes
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Functional Activities
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Therapy Activities
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Dressing with or without AE
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Parquetry
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Applying make-up
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Puzzles
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Grocery shopping
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Tangrams
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Organizing spice rack and or pantry
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Mazes
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Sorting and organizing dishes from the dishwasher
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“Where’s Waldo?”
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Navigating Apps on phone or web browsers
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Graphing
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School and work-based tasks
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Line or design completion
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Environment
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Person
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Occupation
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- Organization
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- Scanning strategies
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- Task analysis (grade up/down)
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- External cues (e.g., increase contrast)
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- Cognitive strategies
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- Oculomotor strategies
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“White-board” Activities
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Eye-hand coordination, peripheral awareness
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Walking Trails
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Visual tracking, spatial and peripheral awareness, gaze stabilization, and balance
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Dowel Stick or Bunting using a Marsden Ball
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Peripheral awareness, eye-hand coordination, and stereopsis or depth perception
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Vectograms
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Convergence and divergence
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Red/Green Activities
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Reduce suppression of one eye while working both eyes simultaneously
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Objective measurement for reaction time and can be used daily
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Applied specifically for individuals returning to driving following TBI and stroke
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Visual speed of processing and reaction time do not solely determine drive readiness
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Contraindications: history of seizure-like activity
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Activities may be done in clinic or given as therapeutic home programs:
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- Speed Typing Tests (several resources online)
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- Structured Internet Searches (i.e. locating a current event article, read it, and write or type a brief summary)
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- Car Scans (i.e. locating street signs, speed limit, etc. with or without moving head)
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- Reading a bedtime story to your kids
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- Scanning and clipping grocery store coupons
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- Grocery shopping (i.e. establish a grocery list of 5 items and increase by 2 items each trip)
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- Send email to therapist every Friday of new activities to add or replace on “functional activity log” for the next week
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Pros
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Cons
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Advanced vision therapy option for higher level goals (driving)
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Fatiguing
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Great for individuals who like objective measures and goals
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Photosensitivity
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Gamers like it
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Screen sensitivity
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Can provide experiences pen and paper can’t (dynamic reader;Tic-tac-toe-tack)
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May be challenging for more severe TBI
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Seizure contraindications
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