Oculomotor & Visual Perceptual Assessment & Intervention
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Binocular Coordination requires effective…
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Smooth pursuits/tracking Saccades Convergence Divergence Stereopsis/Spatial localization Focal and Ambient Visual Processing- Physiological diplopia
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Binocular Dysfunctions due to BI may results in…
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Inadequate gaze stabilization and bifocal fusion Diplopia Suppression (brains response to diplopia) Vergence Insufficiencies (usually convergence) Accommodative Insufficiency (CN III) Visual fatigue due to poor oculomotor control- My eye is starting to sting
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Natural positioning of the eye (everyone has phoria)
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Tendency is to aim in front (esophoria) or behind (exophoria) the point of focus (convergence)
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Fusion is intact
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Depth perception may be intact
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Measured by prism diopters
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Produce subtle symptoms
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difficulty concentrating; frontal or temporal headaches; sleepiness or stinging of eyes after reading
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Visible turn of one eye (constant, intermittent, alternating between both eyes)
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Esotropia: One eye turns in; Exotropia: One eye turns out; Hypertropia: One eye turns up relative to other eye
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Fusion (binocular vision) and depth perception (stereopsis) are not present
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Paralysis of the SR, MR, IR, IO
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Symptoms
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Diplopia; Extraocular weakness resulting in exotropia; Convergence insufficiency; Ptosis-upper eyelid droops; Photosensitivity (if ciliary ganglion affected); Accommodation insufficiency (if ciliary ganglion affected)
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Superior Oblique M. paralysis of the contralateral eye
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Symptoms
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Trauma may result in binocular paralysis; Unable to efficiently complete torsion in (adduction) and down (depression); Hypertropia; Diplopia; Bielschowsky’s Head Tilt Test-affected eye with become more hypertropic with head tilt to affected side; eye gaze appears normal with head tilt to non-affected eye side
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Lateral Rectus M. paralysis
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Symptoms
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Unable to move eye into abduction or laterally toward temporal field of the ipsilateral eye
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Diplopia with temporal gaze
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Divergence Insufficiency
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Esotropic
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Smooth pursuits/tracking
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Patient should follow target with eyes in a “T” then “X” pattern
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Saccades
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Instruct patient to shift gaze between two targets using eyes only. Move the two targets clockwise, keeping each target on opposite sides of the clock, e.g. 3 & 9, 1 & 7, etc.
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Convergence
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Pencil push up; Brock String
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Divergence
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Brock String
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Used to train convergence and divergence
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improves fusion of the eyes and increase peripheral awareness (physiological diplopia)
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Can be fatiguing for individuals with diplopia or impaired visual processing
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Can be challenging to understand for individual with cognitive of memory impairments
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Can measure point of convergence and recovery into divergence with yard stick to assess progress and for goal writing - (point of convergence norm is 6-10cm from nose)
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Long-term effects result in central vision suppression
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peripheral vision remains intact
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Symptoms/signs
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Cover or close one eye OR favor one eye over the other
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Under/over reaching objects
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Double vision
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Under/over reaching objects
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Avoid near activities
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Exhibit head tilt or turning during activities
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Restoration
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Adaptation
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SEE Exercises
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Pacing Programs (Functional Activity Logs)
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Brock String
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Binasal Occlusion
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Field Expansion (central peripheral awareness)
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Prisms
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Accommodative Flippers
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Computer-based activities
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PROS
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CONS
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Great for people with good attention for sustained period of time and decent cognition (e.g., mild TBI)
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Can be very fatiguing
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Advanced vision therapy option for higher level goals such as driving or return to work
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Photosensitivity
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Great for individual who like objective measurements and goals
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May be challenging for more severe BI
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Great for “gamers”
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Seizure contraindications
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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 bed time story to your kiddos
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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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Goal: reduce onset of symptoms of visual fatigue and other symptoms by participating in short spurts over a longer period of time versus long spurts over a short period of time
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Establish a baseline: determine length of time an activity occurred resulting in onset of symptoms
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Establish the most effective strategy for reducing symptoms (i.e. meditation, laying down in a dark and quiet environment, covering eyes with palm of hands with slight application of pressure)
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Establish a “Pacing” Plan: terminating or pausing an activity prior to onset of symptoms; then resuming activity after symptoms subside
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Deviates an images toward its apex
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Eye must also turn toward the apex of the prism in order to remain aligned with the image
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EX: if one eye has a tendency to turn away from an object due to a muscle imbalance, prism can be prescribed to shift the image in the same direction
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allows the eye to rotate to a more comfortable position, while still remaining aligned with the image
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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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Create a “functional activities log” or “pacing program”
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- Tracking specific activities that are perceived triggers for onset of symptoms (i.e. computer or screen-time, reading, scanning for grocery items, eating in a crowded restaurant, riding as a passenger in the car, etc.)
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Increasing awareness of physiological diplopia and peripheral fields
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Shifting the image allows for increased comfort improving eye fusion
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increases of expands peripheral awareness improving visual field loss and ambient visual processing
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Diplopia may be eliminated
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Alters the persons perception of reality improving midline shifts
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Typically used in conjunction with vision therapy and functional activities
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Can treat visual dysfunctions while eliminating need for patching an eye (monocular vision)
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Should only be completed with recommendations supplied by neuro-optometrist
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Central Taping Occlusion
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Patching
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- Occluding central vision to reduce diplopia
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- Complete occlusion of non-dominant eye
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Pros: Benefits allowing peripheral vision processing to remain exposed to sensory feedback
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- Ideally alternating patch to eliminate risk of suppression
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Cons: May be visually distracting for patients who have additional cognitive/perceptual dysfunctions
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- Alternating schedules are dependent of patient's tolerance (phoria vs tropia)
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Pros: allows for immediate relief of double vision
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Cons: Utilizing monocular vision only can result in suppression due to no sensory feedback in non-used or affected eye
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Binasal Occlusion is a non-invasive method and is easy to apply in patients with mTBI and motion sensitivity
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Reduces the symptoms caused by increased motion sensitivity and double vision
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Provides immediate and sustainable effects by reducing stress with visual processing
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May enhance performance during activities of daily living, hobbies, and work related activities
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Goal is to strengthen the peripheral field awareness (ambient processing) while engaging in central vision activities resulting in field expansion
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This strategy improves gaze stabilization which improves reading skills, identifying obstacles quickly and efficiently, and improve anticipatory response time to reduce risk of falling
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Must have adequate attention, arousal, and cognitive function to successfully use this strategy
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Kinetic Confrontation (behind person)
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Confrontation Field Testing (in front of person)
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Collides of comes very close to obstacles on one side in an unfamiliar environment
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Stares straight ahead at the floor immediately in front of them
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Consistently stares to one side
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Uses finger to “trail” wall to guide self
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Refuses to take the lead when ambulating, preferring to walk behind others
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Anxious or uncertain in crowded areas
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Stops walking when approaching or passing by another moving person or object
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Complains of feeling off balance particularly to one side
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1. Right Eye Anopsia/Blindness
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2. Bitemporal heteronymous hemianopsia
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3. Binasal heteronymous hemianopsia
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4 & 5. Contralateral homonymous hemianopsia
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6. Contralateral upper quadrant anopsia
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7. Contralateral homonymous hemianopsia with macular sparing
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Increase awareness to affected visual field through adaptation
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- Visual scanning to affected side requiring head turning to scan surroundings
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- Visual aides or markers to ensure the individual know how far to scan
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- Position self on the side of affected visual field when looking far away (i.e. during a presentation, movie theater, etc.)
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- Have someone walk on the side of the affected visual field
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Prism lens may help with visual field expansion as prescribed by neuro-optometrist
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Central peripheral Expansion?
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Judgement of space and distance- Stereopsis (depth perception)
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Functional observations that can impact safety
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Can be affected by…
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- Difficulty negotiating steps, stairs, or curbs or safely navigating around environmental obstacles
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- Changes in acuity
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- Pouring hot coffee without spilling or reaching for skillet handle on stove top without burning self
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- Contrast sensitivity
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- Not stopping soon enough at a red light/stop sign or difficulty determining distance of exit/street sign resulting in last minute turning or missing exit
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- Poor integration of focal and ambient visual processing systems
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- Divergence and/or convergence insufficiencies (binocular vision dysfunctions)
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OT TESTING
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Finger to nose test
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OPTOMETRIST TESTING
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The Randot Stereotest
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MVPT-4
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DTVP-A
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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
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External Cues (e.g. Increasing Contrast)
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Cognitive strategies
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Oculomotor Exercises
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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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Organizing groceries to put away
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“Where’s Waldo?”
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Sorting and organizing dishes from the dishwasher
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Graphing
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Sorting and folding laundry
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Line or design completion
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Setting the table
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Any activity involving constructional praxis (e.g., 3-D building tasks)
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Organizing medications
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Navigating Apps on phone or web browsers
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Cheatography n. The art of mapping complex subjects into clear, instantly navigable reference guides.
