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How to Identify and Remedy Common Vision Disorders Resulting

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How to Identify and Remedy Common Vision Disorders Resulting from TBI
Kevin M. Chauvette OD, FCOVD
Merrimack and Manchester, NH
Overview
Frequency of vision disorders in TBI
How we are wired
Most common symptoms
Screening techniques
Simple therapy techniques
When to refer
Interesting cases
пЃ® Traumatic Brain Injury (TBI)
Statistics
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1.7 million people / year in the US acquire a TBI and over 50% of these suffer from
visual impairment (CDC 2012)
1 out of 500 school children hospitalized each year for a TBI
TBI is the leading cause of death and disability of children and adolescents in US
“Mild” TBI are the most common type of TBI
20% of mTBI never return to work
Visual Processing Following Brain Injury
50-75% of severely brain injured individuals had visual processing problems which
required further professional exploration by an ophthalmologist or optometrist
(Gianutsos et al)
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72 y.o female recovering from R fronto-parietal meningioma
Focal seizures
Ataxia
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Apparent L visual field neglect
R gaze preference
What do you do?
Send for Neuro ophthalmology consult
Report says: “Pt has normal visual acuity, bilateral cataracts and otherwise normal
ocular health. A Vis field was unable to be completed due to poor cooperation…
and she s/p R fronto-parietal meningioma”.
Was this helpful?
54 y.o male involved in a MVA with L SDH
Pt c/o extreme dizziness
Unable to track or maintain vis attention
Seems to “miss things” on R side
Difficulty reaching accurately for objects in front of him
What do you do?
Ophthalmology consult
Report: “pt has photophobia secondary to a traumatic brain injury. Eye health is
normal. Vis field is normal with high false positives due to poor fixation control.
Return in 6 months to re-evaluate.”
Does that help you determine a treatment plan for this patient?
The Three O’s
Ophthalmologist – Eye surgeon
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Neuro-ophthalmolgy (where is the lesion)
Medical/surgical diagnosis and treatment of neurological disorders
Optometrist – evaluation, diagnosis, and treatment of the functions of the visual
systems
The Three O’s
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Neuro Optometry/Neuro Optometric Rehabilitation (<1% of profession)
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Neuro optometrist should be part of the rehab team (whenever possible)
Optician – makes and dispenses eyewear
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Non-medical professionals
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Vision Rehabilitation:
Neuro-Optometric (NOR)
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Identify visual-motor, visual-spatial processing, and visual-information-processing
dysfunctions in the neurologically affected person.
Correlate these visual dysfunctions with ADL dysfunctions
Develop a plan of visual rehabilitation to maximize ADL’s
NOR Therapy / Management
Lenses – non-compensatory (near, far, astigmatism)
Prisms – non-compensatory
Selective occlusion
Filters
Vision therapy
VEP visually evoked potential
NOVAVISION VRT - visual restoration therapy
Syntonic Light Therapy
Combinations of the above
Visual Processing Following Brain Injury
пЃ® 38% of acute traumatic brain injured individuals had vergence (eye teaming
control) difficulties
пЃ® 42% of these had vergence insufficiencies at a 3 year follow-up
(Cohen et al)
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Visual Processing Following Brain Injury
79% of brain injured individuals in one study had strabismus with diplopia
(Mitchell, MacFarlane, and Cornell)
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Visual Processing Following Brain Injury
пЃ® 20% of all stroke patients in their study suffered from some sort of visual problem
(Samo and Samo)
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Visual Processing Following Brain Injury
59% of brain injured patients in their study displayed visual problems
(Schlageter, Gray, Hall, Shay, and Sammet)
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Visual Processing Following Brain Injury
60% of stroke patients had unilateral neglect
(Adams and Hurwitz)
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Visual Processing Following Brain Injury
20% of all individuals admitted to a rehabilitation center had perceptual problems
and that these were clearly associated with increased length of stay in the hospital
and an adverse effect on discharge and subsequent placement
(Ferguson, McCarthy, Greenberg, and Feingenson)
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Studies are widely varied
Depends on the pt population
Depends how you classify “vision problems”
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Tracking?
Attention?
Spatial judgment?
Sensory changes?
Patient’s perception of vision problems
Distance and near “sight”.
Clarity only
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They may have VF loss or significant perceptual changes, but may deny having
visual problems
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The eyes are for seeing…
пЃ® More than 30% of the human cortex is devoted to vision and visual processing
connections with non-visual systems.
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The eyes are for seeing…
Of approximately 1 million nerve cells per eye that are involved in processing light,
more than 80% travel to the visual cortex to be used in eyesight.
20% of the direct retinal fibers connect with “non visual” cortical areas more
commonly associated with balance, emotion and memory.
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Why is NOR required?
пЃ® 80% of the brain is connected to visual processing
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When is NOR required?
As soon as (ASAP) visual dysfunction is identified or is suspected in interfering
with the progress of rehabilitation.
How to get a brain injury:
How to get a brain injury:
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Vision Problems Encountered
Medical Problems Encountered:
Dry eyes
Glaucoma
Cataracts
Diabetic Retinopathy
Macular Degeneration
Vascular Occlusive Disease
Other Retinal Degenerative Diseases
Sight Problems Encountered
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Sight
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Acuity
Contrast Sensitivity
Color Vision
Glare Sensitivity
Visual Field
пЃ® Functional Vision Problems Encountered
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Ocular-Motor Problems
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Fixation
Pursuits
Saccades
Nystagmus
Vestibular-Ocular Reflex
Pupils
Accommodation
пЃ® Functional Vision Problems Encountered
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Visual Processing Problems
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Visual-Motor-Integration Skills
– Handwriting
– Reach & Grab
– Ambulating
– Driving
пЃ® Functional Vision Problems Encountered
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Visual Processing Problems
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Visual-Analysis Skills
– Visual Discrimination
– Visual Closure
– Visual Form Constancy
– Visual Figure Ground
– Visual-Spatial Relations
– Visual Memory
– Examples….
Visual Discrimination
Visual Closure
Visual Form Constancy
Visual Figure Ground
Visual Spatial Relations
Visual Memory
Visual Memory
пЃ® Functional Vision Problems Encountered
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Visual Processing Problems
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Visual–Motor Integration Skills
Visual Analysis Skills
Visual-Spatial Skills
– Visual Midline
– Unilateral Spatial Inattention (Neglect)
– Visual Multitasking
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Visual Spatial Problems
THE MAJORS
“The Dangerous Ones”
All 6 are Visual-Spatial Problems
Diplopia
Visual Field Defects
Unilateral Spatial Inattention (Neglect)
Visual Midline Shift Syndrome
Post-Traumatic Vision Syndrome
Visual Multitasking Dysfunction
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THE MAJORS
“The Dangerous Ones”
“The Disabling Ones”
All 6 can slow the rehab process
All 6 can lead to greater risk of subsequent injury and illness
All 6 can lead to adverse psychological sequellae
All 6 can lead to more medications
All 6 can lead to greater dependence on others
Diplopia (double vision)
Occurs when the eyes do not point in the same direction at the same time.
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Ocular Trauma
Cranial Nerve Palsy (3rd, 4th, 6th)
Supranuclear Palsy
Decompensation
Visual-Spatial Dysfunction
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Diplopia
Not always reported by patient.
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May claim “blurry vision”
Patient may exhibit postural shifts
Can cause dizziness / vertigo
Can cause visual-motor-integration problems
Eliminated by covering one eye but, patching is not the best treatment
Diplopia may be intermittent
Convergence insufficiency
Convergence excess
Test with NPC or Brock posture board
Diplopia Treatments
compensatory prisms
partial occlusion
vision therapy
total occlusion
patching
surgery
When compensatory prism does not work…
Try selective occlusion
Therapy Activities for Eye Teaming
Brock String
Vectograms
Aperture Rule
Computerized activities
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START BY ENSURING MONOCUALR SKILLS ARE EQUAL!
Tranaglyphs and Vectograms
Aperture Rule
Computerized activities
Visual Field Defects
Unilateral
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Central scotoma
Paracentralscotoma
Superior and Inferior
Concentric
Homonymous Hemianopsia
Unilateral Spatial Inattention (Neglect)
Homonymous Hemianopsia
Bump into objects on one side
Can’t find objects on one side of the room
Says they can’t see out of one eye
Is surprised by objects or people that seem to pop into view
Is aware of their deficit
High accident risk for elderly
Peli Prism
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Pre VRT
Post VRT
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30 minute home therapy 2 times daily
6 months of therapy
70% have shown an increase of at least 5 degrees of visual field
Ideal candidates: High functioning stroke patients, pts with vision loss from brain
tumor or traumatic brain injury
Unilateral Spatial Inattention
“Neglect”: term connotes a purposeful act
Damage to the right posterior parietal lobe
Mostly seen on left side
Can be with or without field defect
Generally causes visual midline shift
Patient at high risk of injury
Patient has higher dependency
Patient is unaware of their deficit
Unilateral Spatial Inattention
Bumps into things on one side
Can’t find things on one side
May not shave or dress one side
May not use one side of body (even non-paralytic)
Orients and postures away from USI side
Doesn’t know to look in direction of USI
Is unaware that there is space that they can look into
May not be able to turn eyes in USI direction
Samples of L Neglect
“I’m finished shaving”
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Unilateral Spatial Inattention
3 Key considerations:
Pt is prone to Extinction Phenomenon, in terms of body and in the two visual
spaces
Can occur in the presence or absence of a basic motor or basic sensory
dysfunction
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Key is an unawareness or denial of the USI
Draw a Clock – CW vs. CCW
3 weeks post
R MCA CVA
L VF full to FC
but shows strong L neglect to Bilatsimult stimulation
1 week later
no dual extinction when sitting, but extinction exists when standing
2 weeks later,
no dual extinction when sitting or standing.
Pt is better able to integrate R & L hemispheres
Right Neglect?
VF Treatment
Penlight field awareness
Peripheral visualization
Eye throwing
Hallway splitting
Headlight pointing
Post-it note awareness
Flashlight tag
Peripheral playing cards
Equipment
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THE MAJORS
“The Dangerous Ones”
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Diplopia
Visual Field Defects
Unilateral Spatial Inattention (Neglect)
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Visual Midline Shift Syndrome
Post-Traumatic Vision Syndrome
Visual Multitasking Dysfunction
Visual Information Processing
Two separate processes
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Focal process (mostly the 80% of visual processing)
Ambient process (mostly the 20% of visual processing)
Focal Visual Process
Through the macula (detailed vision)
Through the peripheral vision (detailed attention process)
80% of the fibers leaving the eyes go to the Occipital Cortex
Ambient Visual Process
20% of the fibers leaving the eyes go to the Midbrain
Provides ambient information used for
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balance
movement
coordination
posture
Lets you know where you are in space
Ambient Visual Process
Part of the sensory motor feedback loop in the midbrain
Matches up with information from the following systems for the purpose of
orientation and acting as a master organizer of these other systems:
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kinesthetic
proprioceptive
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vestibular
tactile
CAUSES A SUPPRESIVE FEEDBACK LOOP TO THE FOCAL PROCESSING
SYSTEM (processing deficit basis in USI)
Major Ambient Visual Process Syndromes
Visual Midline Shift Syndrome (VMSS)
Post-traumatic Vision Syndrome (PTVS)
Visual Midline Shift Syndrome
(VMSS)
Patient has mismatch in perception of space related to self
Common Characteristics
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Dizziness or nausea
– (balance, coordination, and posture)
Spatial disorientation
Leaning forward / backward / one side
Other associated Neuro-motor difficulties
Visual Midline Shift Syndrome
(VMSS)
Common Characteristics
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Seeing the floor tilted
Illusions of movement of environment
Constantly walking to one side of hall or room
Bumping into objects when walking
Leaning to one side, back or forward or posture changes
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Post Trauma Vision Syndrome
(PTVS)
Common Characteristics
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exotropia / exophoria (eyes turned out)
convergence insufficiency
accommodative insufficiency
ocular motor dysfunction
Post Trauma Vision Syndrome
(PTVS)
Common Characteristics
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Increased myopia or nearsightedness (almost every ABI pt. over time)
Low blink rate
Spatial disorientation
Poor fixation
Unstable ambient vision
Post Trauma Vision Syndrome
Complain of:
Common Symptoms
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Diplopia
Blurred or hazy vision--ghost images
Inappropriate motion sensation, dizziness, nausea
Headache, especially when reading
Glare or light sensitivity
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Post Trauma Vision Syndrome
(PTVS)
Common Symptoms
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Headache with light exposure (photophobia)
Dry eye syndrome
Reading problems
– including unstable focusing, poor line tracking, losing place in text,
poor comprehension and memory of text
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PTVS is common in mild TBI
Why aren’t mild TBI’s picked up on MRI?
MRI is “macro” scale – ¼ mm best resolution
Cell level is 1/1000th of mm
Damage within a neuron = 1/1millionth of mm
How much force does it take …
Head laceration/bruising?
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300-400 lbs of pressure
To break a car window?
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500-700 lbs of pressure
To crush skull?
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1000 lbs of pressure
Visual Multitasking
Simultaneous Central / Peripheral Visual Processing
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The ability to attend to a central visual target and simultaneously respond to
peripheral visual stimuli.
Visual Multitasking Dysfunction
Virtually ALL brain-injured patients have some dysfunction of this ability
They approach the world with a “tubular-vision” approach, sequentially looking at
one thing at a time.
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Significantly slows “Speed of Processing” down
Visual Multitasking Dysfunction
Anxious in crowds
Difficulty shopping
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Overwhelmed by too much stuff
Gets lost easily in store
Driving is dangerous
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Poor lane maintenance
Anxious with increased traffic and speed, or night driving
Dizziness
Dizziness – 3rd most common out pt complaint
40-80% unexplained by PCP
Common in mTBI
Imbalance between signal from vestibular system, visual system and
proprioceptive system
Screening for vestibular dys
Dynamic visual acuity
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Move head back/forth look for drop in VA
Grade dizziness level sitting, standing moving, environment moving, turning
VOR response
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Thrust head to one side while looking at you
Egocentric localization
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Point nose at my nose, or at specific object
Treatment
Selective occlusion
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Binasal – Decreases peripheral processing load to enable hypo-thalamic
tract function
Bitemporal – works with long standing exofusional difficulties
Sectoral – as needed
Binsalocclussion
Treatment
Filters
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Glare = disorganized light
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Polarization – organizes light in straight lines to reduce glare
– Tints – reduce the total amt of light
– Gradient – darker on top
– Transition – change with light exposure
– Combinations
Treatment
Vision therapy
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Eye movement – must be SLOW and in developmentally correct order –
vertical, horizontal, rotational, then diagonal
Vestibular (root of eye movements)
Vergence ranges (range of motion for VOR)
Awareness – peripheral awareness stationary/mobile
Ambulation
Infinity Walk
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Arousal, Attention
and Modulation
пЃ® Basic Activities
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Turn and Clap
Turn and Catch
Treatment
Syntonic Light Therapy
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Turn and Touch
Applied use of specific wavelengths to the eyes for specific changes to blood
chemistry (affecting endocrine)
Started in the 1900’s by Spitler, MD. Used in many other countries
www.syntonicphototherapy.com
The Efficacy of Vision Rehabilitation Therapy
Training of visual scanning reduced neglect in right damaged stroke patients
(Diller and Weinberg)
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4/5 studies reviewed (150 patients) found consistent beneficial effects of visual
processing skills training for the patients which were over and above improvements
resulting from conventional therapy
(Gianutsos and Matheson)
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The Efficacy of Vision Rehabilitation Therapy
Research indicates that visual processing therapy has a possibility of reducing the
size of the visual field problem
(Warren)
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Visual processing gains through therapy are maintained a year after discharge
(Weinberg et al)
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What is Vision Therapy?
“…a clinical approach for correcting and ameliorating the effects of eye movement
disorders, non-strabismic binocular dysfunctions, focusing disorders, strabismus,
amblyopia, nystagmus, and certain visual perceptual (information processing)
disorders. The practice of vision therapy entails a variety of non-surgical
therapeutic procedures designed to modify different aspects of visual function.”
Advanced Therapist Vol. 34, Number 1, p. 131
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Locating a Doctor
To locate a Neuro-Optometric Rehabilitation Specialist
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www.covd.org vision development
www.nora.ccneuro rehabilitation
kchauvette@merrimackvision.com
Merrimackvision.com
Eyeqvisiontherapy.com
For More Information
www.merrimackvision.com
www.nora.cc
www.covd.org
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Kevin M. Chauvette, O.D., FCOVD
(603)424-0404 Merrimack, NH
(603)644-6100 Manchester, NH
kchauvette@merrimackvision.com
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References
[1] Padula WV, Shapiro JB, Jason P. Head injury causing post trauma vision
syndrome. New England Journal of Optometry 1988;41(2):16–21.
[2] Schlageter K, Gray B, Hall K, et al. Incidence and treatment of visual
dysfunction in traumatic brain injuries. Brain Inj 1993;7:439–48.
[3] Portas CM, Rees G, Howseman AM, et al. A specific role for the thalamus in
mediating the interaction of attention and arousal in humans. J Neurosci
1998;18(21):8979–89.
[4] Klemm WR. Understanding neuroscience. St. Louis (MO): Mosby; 1996. p.
101–52.
[5] Casagrande VA, Royal D. Parallel visual pathways in a dynamic system. In:
Kaas JH, Collins CE, editors. The primate visual system. Philadelphia: CRC Press;
2003. p. 1–28.
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[6] Van Gelder RN, Wee R, Lee JA, et al. Reduced pupillary light responses in
mice lacking cryptochromes. Science 2003;299(5604):222
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References
[6] Van Gelder RN, Wee R, Lee JA, et al. Reduced pupillary light responses in
mice lacking cryptochromes. Science 2003;299(5604):222.
[7] Brainard G, Hannifin J, Grison J, et al. Action spectrum for melatonin regulation
in humans: evidence for a novel circadian photoreceptor. Neuroscience
2001;21(16):6405–12.
[8] Pickard G. Studies of circadian rhythms. As reported in Insight: The College of
Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort
Collins, Colorado 2002;29(2):4–5.
[9] Thapan K, Arendt J, Skene DJ. An action spectrum for melatonin suppression:
evidence for a novel non-rod, non-cone photoreceptor system in humans. J Physiol
2001;535(1):261–7.
[10] Moseley MJ, Bayliss SC, Fielder AR. Light transmission through the human
eyelid: in vivo measurement. Ophthalmic Physiol Opt 1988;8(2):229–30.
[11] Zelinsky. Rehabilitation. Phys Med RehabilClin N Am. 18 (2007) 87–107
Eye Teaming
Brock String
Objective: To teach the equal use of both eyes at the same time. It
further develops your ability to shift two eyed vision from one point in
space to another point quickly and easily without suppressing (turning
off the information) one eye. BOTH EYES ARE OPEN!
Materials: A six foot piece of string with buttons or beads of different
colors in used. The beads are spaced evenly along the string.
Fasten one end of the string to any convenient object at or slightly
below the proper eye level for the patient. Have the patient hold the
other end of the string between their thumb and forefinger just below
their nose. Stretch the string tightly so that it extends from the nose
to its fastened end in a straight line.
1. Make an X:
Have the patient look at a selected bead and they should see
what looks like two strings emerging from the side of their head
and meeting in a “V” or “X” at the selected bead. The other
beads not fixated should also be seen as double.
2. Movable X:
As improvement occurs place the beads at other spots on the
string but closer and farther away. As attention is shifted from
one bead to another the “X” should immediately be seen with
the center of the “X” exactly at the bead.
Note: If only one string is observed it is indicative of suppression of
one eye. In order to see two strings have your patient blink rapidly or
shake the string.
Eye Tracking
Manual Eye Tracking
Objective: To achieve smooth accurate eye muscle control when
following a moving object or moving the eyes along a line of written
words.
Materials: Spoon & fork, or two distinctly different objects of similar
size. Eye patch.
Therapist should hold spoon with convex (curved out) side facing
patient. Slowly move the spoon in a circular pattern being sure to
check that patient's eyes are accurately following target. Increase
speed and randomize the pattern as patient's tracking becomes more
advanced.
Next, with the fork in one hand and spoon in the other, have patient
look intently at image in spoon. While patient is looking at spoon,
move position of fork and then ask patient to look at the fork. Check
to be sure that he/she accurately locates fork without searching. Then
move the position of the spoon while patient is looking at fork. Make
sure he/she does not try to look at spoon until you give the command.
Increase speed as patient becomes more accurate.
Thumb Rotations
The patient should be standing or seated comfortably with good
posture.
An eye patch should be worn over the left eye first, then switched to
the other eye to repeat the procedure. The patient should hold one
arm outstretched with thumb pointing up. They are to move their
thumb in a large circle, keeping the head straight and moving only
their eyes to follow their thumbnail. They should be aware of objects
their thumb is passing in their peripheral vision. To increase skill
level, patient should mention all objects they see as they are moving
their thumb.
Try to move the thumb slowly at first and bring it out as far as
possible until it can be tracked with more skill. Then trace the thumb
in an 'X' pattern and in a '+' pattern as scheduled below:
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п‚·
10
10
10
10
O's (clockwise).
O's (counter clockwise).
X's
+'s
Be aware of any pressure or pulling on the eye muscles when
following the thumb. This pulling gives necessary feedback as to the
precise location of the eyes.
Head Shifts
While maintaining steady fixation - this activity may be more
appropriate for lower level patients who have difficulty following
commands or those patients with apraxia.
Select a distant target approximately 6-10 feet away from patient at
eye level. The target should be detailed enough and interesting
enough to keep the patient's fixation throughout the activity (i.e.
family members face, television screen, photograph, etc.) While the
patient is viewing the distant target, the therapist shifts the patient's
head position slowly to the right and to the left, as if shaking the head
“no”. Patient should also be instructed to nod the head up and down
while maintaining fixation on the target. Difficulty can be increased by
instructing the patient to rotate their head in a clockwise or
counterclockwise pattern while continuing to maintain fixation.
Rice and Tweezers
Materials: several medium to large grains of uncooked rice, one set of
metal or plastic tweezers, container with 2-4 inch diameter opening.
With one eye patched, the patient is instructed to use the tweezers to
pick up grains of rice and drop them into a cup as quickly as possible
within a 3-minute period of time. The patch is then moved to the
opposite eye and the activity is repeated. The therapist should count
the number of grains placed into the container each time the activity
is performed to measure improvement of speed and accuracy. The
patient's appropriate near point eyeglasses should be worn at all
times during the activity. If there is a possibility of a convergence
problem, the patient should also perform the activity with both eyes
open.
Depending on the motor ability of the patient, this activity can be
modified by having the patient pick up blocks or other larger sizes
objects using either their thumb and forefinger or a grasping device.
Filling in O's
Materials: Fine tip marker, newspaper or magazine, eye patch.
The patient is given 5 minutes to fill in as many letters that he/she can
find that contain a closed symbol (o,b,d,g,p,q) with the eye patch
placed on the right eye first, the patient is asked to fill in as many
"o's" as possible. Then repeat with the eye patch placed on the left
eye. If the patient has a tendency to neglect one side for the other, a
pattern may be seen with the letters being darkened on the opposite
side only. The patient may then be shown his/her completed activity
pointing out that they have missed many more letters on one side
than the other and encouraging them to scan first into their weaker
field. This can improve the patient's ability to compensate for a
neglected or hemianopic field.
Flashlight Tag
Materials: 2 flashlights, colored acetate to make one light a different
color.
The therapist and patient face a blank wall in a darkened room from a
distance of 8-12 feet. Both flashlights are shined onto the wall and the
patient is made aware of which light is theirs. The therapist moves
their light quickly to one side and stops. The patient is asked to
quickly locate the light and place their light on the other light. This is
repeated in different directions giving prompting when the patient
cannot locate the light. The therapist can then play "Follow the
Leader" by moving their light slowly and asking the patient to keep
their light on top of the therapist's light.
Michigan Tracking
Materials: Michigan tracking letter paragraphs, eye patch,
appropriate near point correction, pen or pencil.
With one eye patched, patient is asked to track from left to right
beginning at the top left letter as if they were reading. They will
search for the very first letter 'A' that they come to and cross it out.
They will then proceed to the right looking for the letter 'B', then 'C',
etc. When the patient gets to the end of one line, they must proceed
to the next line without looking back to the line that they have just
completed. If they perform the task completely, they should have all
of the letters of the alphabet crossed out by the time they have
reached the end of the paragraph. If they reach the end of the
paragraph and have not found all of the letters, they must start back
at the beginning looking for any letters they have skipped over. This
activity should be timed for measurement of improvement in
scanning. The task should be done monocularly using an eye patch
to occlude one at a time, then binocularly using both eyes together.
Hart Chart Saccades
Objective: To increase the speed and accuracy of saccadic fixations.
Materials: Large Hart chart for distance viewing, eye patch
Place the Hart chart about 5 to 10 feet from the patient. Occlude
patient’s left eye with an eye patch and instruct the patient to call out
the first letter in column one and then the first letter in column ten, the
second from the top letter in column one and the second letter from
the top in column ten, the third letter from the top in column one and
the third letter from the top in column ten, etc. Continue until the
patient has called out all letters from columns one and ten. As the
patient calls out the letters, write down his responses and when the
task is completed have the patient check his accuracy. Requiring the
patient to check for errors is in itself another saccadic therapy
technique. Now the patient will have to make saccades from far to
near to check for errors.
Once this task can be completed in about 15 seconds without any
errors, you can increase the level of difficulty several ways. Ask the
patient to continue calling out letters in the other columns.
Specifically, after completing columns 1 and 10, have the patient call
out columns 2 and 9, 3 and 8, 4 and 7, 5 and 6. The inner columns
are more difficult because they are surrounded by other targets.
An even greater level of difficulty can be achieved by requiring
saccades from the top of one column to the bottom of another.
Instead of a left to right and right to left saccade, the patient will have
to make an oblique saccade. For example, ask the patient to call out
the top letter in column one and then the bottom letter in column ten,
the second letter from the top in column one and the second letter
from the bottom in column ten. Continue this pattern through the
entire chart.
Many other variations to increase the level of difficulty are possible
including, the use of multiple Hart Charts, split Hart Charts,
incorporating the beat of a metronome, and requiring the patient to
maintain balance board while engaged in the task.
Rotating Pegboard
Materials: One variable speed rotating peg board from Bernell (1800-348-2225) colored pegs or golf tees, red/green glasses (for
increased difficulty only).
Patient is seated within arms length of the peg board. The therapist
initiates movement of the pegboard at the slowest possible speed in a
clockwise direction and instructs the patient to place pegs into the
openings along either the green or red lines. Once the patient is able
to perform the task easily, have them follow the selected opening with
the peg held an inch or two above the whole for one complete
rotation before inserting the peg into the opening. To further increase
difficulty, patient's can be asked to place the pegs into the peg board
with the non-dominant hand or while balancing on one leg or a physio
ball. If red and green colored pegs are being used, the therapist can
incorporate red/green glasses to provide cancellation of one of the
colors by each eye. This will help check for and eliminate any
suppression that the patient may be experiencing. If the patient has a
neglect or hemianopsia, place the pegboard in the patient's weaker
field to encourage standing into the missing field.
GAZE PREFERENCE TREATMENT
GAZE PREFERENCE TREATMENT
Directions:
Seat the patient in rotating office-type chair. If the patient is wheelchair bound, place the wheelchair on
rotating board or simply rotate the patient in the wheelchair.
Rotate the patient in the chair at a speed of one full rotation per second for a maximum of ten times with
the patient’s eyes closed. Rotation should be in the direction of the gaze preference (if eyes are “stuck to
left” rotate patient to the left). Direct the patient to open his/her eyes and look straight ahead. Examiner
should see a nystagmus movement in the direction of the rotation and the patient’s eyes should involuntarily
move in the opposite direction of the gaze preference. This may only last for 20 to 30 seconds before the
eyes go back to their normal position. Asking the patient to maintain straight-ahead fixation on a particular
object and attempt to hold fixation for as long as possible. Repetition of this activity can help to maximize
the patient’s ability to work their way out of this abnormal eye posture.
This treatment should be done three or four times to allow for maximum release of the gaze preference.
The goal should be to watch for voluntary movement of the eyes in to the opposite direction and holding
straight ahead gaze for as long as the patient is able to do so.
Hemianopsia Neglect
Penlight Field Awareness
Objective: To increase the patient’s awareness of his/her field deficit
and to improve their ability to compensate by constantly scanning into
the area of loss.
Materials: Two small hand-held penlights
With patient seated in front of therapist, alternately stimulate the
patient’s normal field and abnormal filed with penlight held
approximately 20 degrees to patient’s temporal side. Patient is
instructed to quickly move their eyes to look at the light that is turned
on. Even in patient’s abnormal field, he or she should see the glow of
the light and make a refixation movement to look at the light. If the
patient seems to be unresponsive to the light in their abnormal filed,
move the light closer to their midline. As the patient becomes more
comfortable with the procedure, slowly move the penlight further form
the midline or perform the procedure monocularly for increased
difficulty. After each correct refixation, the patient should look straight
ahead at the examiner to await the next target. At first, any amount
of head movement is allowed in the refixation process; however,
gradually try to reduce the head movement and allow a wider
saccade.
Peripheral Visualization
Materials: None
With patient seated or standing comfortably in a room with minimal
distraction, have the patient scan to the side of their damaged field.
Ask the patient to remember as many objects off to the side as
possible. Have the patient look straight ahead and attempt to
visualize all of the objects that were in their missing field. With the
patient still looking straight ahead, ask them to point to the area
where they remember a particular object to be, for example, a
window or a door knob, etc. While the patient is still pointing, have
them turn their head so that they can now view the missing field and
check to see if their visualization of that field was correct. Repeat this
procedure until consistent and accurate responses are given.
This procedure can also be done as a home technique to rebuild
awareness in a neglect and to aid in compensatory strategies in a
hemianopsia.
Eye Throwing
Objective: To improve the patient's ability to scan for objects in their
weaker field.
Materials: None
Have patient sit comfortably and view a selected fixation target at a
comfortable distance directly in front of the patient. Select a second
fixation target approximately 30 to 40 degrees into the patient's field
of loss.
For a left hemionopsia/neglect, the patient will look to their right (with
their eyelids closed) and develop the feeling of “throwing” their eyes
as far to the left as possible. When they open their eyes, they should
be looking to the left of the second fixation object. They should be
able to easily move their eyes to the right to fixate on that object. Hold
it for approximately 5 seconds. Next, they look back at the center
object of fixation and repeat the activity attempting to throw their eyes
slightly further to the left each time the activity is performed.
For a right hemianopsia/neglect, the patient will begin by looking to
their left and throwing their eyes as far to the right as possible past
the pre-determined object of fixation and then making a quick
refixation to the target for approximately 5 seconds.
A normal saccadic eye movement is often difficult for these patients
since the second target is often located in the patient's blind field.
Making the large eye-throwing maneuver allows the target to be
located within the patient's dominant field making the location of the
target much simpler.
Hallway Splitting
Materials: Yard stick or measuring device.
The patient should be asked to walk down a long corridor or hallway
keeping the area on their left and right exactly equal. If the patient
tends to walk closer to one side than the other, they should be
stopped and the therapist should measure the distance to the wall
from their right and from their left. The therapist should then make the
necessary adjustment to the patient so that they are, once again, in
the center. This type of feedback allows the patient to make
necessary compensations for their disrupted spatial perception. Once
the patient is fairly accurate at splitting the hallway, the therapist may
add a strip of scotch tape down the center of the patient's spectacles
covering the entire pupil. This forces the patient to utilize their
peripheral vision when performing this activity.
Headlight Pointing
Materials: Hat or helmet with laser pointer or flashlight attached to
top.
With light mounted on top of patient's head, the therapist calls out
different objects in the room. The patient then looks directly at the
object making sure the light illuminates the correct target.
Once the patient shows some skill with the basic technique, the light
can be turned slightly in the direction of the field loss. This requires
the patient to make a saccadic eye movement into their missing field
to check for accuracy of the light on the target.
Head Touch Fixations
Materials: None
Therapist should stand or sit behind the patient and randomly touch
them on the side of their head asking them to quickly look in the
same direction that they are touched. A second observer may be
necessary in front of the patient to monitor the patient's success with
moving their eyes in the appropriate direction. The patient should
hold their fixation in the specified direction as long as the therapist is
touching the temple area and should look straight ahead when
neither side is touched.
Patient's with hemianopsia/neglect will typically perform much better
on their dominant side, but may have great difficulty maintaining
fixation in the direction of their missing field. The therapist should
alternate sides, but should give greater attention to the patient's
weaker field.
Solitaire
Cards should be spread out in a wide field of view in front of the
patient, making it necessary for the patient to continually saccades
into their neglected field.
Peripheral Playing Cards
Therapist should isolate 6 to 12 pairs of matching cards and randomly
affix them to the wall to the right, left and center wall of a small room.
Keep in mind that patients are going to be asked to match up “pairs”
of cards so place one card on the right wall and its pair on an
opposite wall, whenever possible. The patient is then asked to find
as many pairs of cards as possible by searching the wall on their left
and matching it with the appropriate card on the right. The therapist
can also request that the patient seek out specific cards and find its
pair.
To increase difficulty, visualization skills can be used by asking the
patient to scan one wall and remember the location of as many cards
as possible. The patient is then allowed to search the opposite wall
and identify as many matching pairs as they can remember.
To further increase difficulty, the patient can be given a set time of 1
to 2 minutes to find as many matched pairs as possible. This score
can be measured against the patient’s own best score from prior days
as an incentive to improve their processing speed.
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