How to Identify and Remedy Common Vision Disorders Resultingкод для вставки
пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® 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 пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® 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 вЂњMildвЂќ 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) пЃ® пЃ® пЃ® 72 y.o female recovering from R fronto-parietal meningioma Focal seizures Ataxia пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Apparent L visual field neglect R gaze preference What do you do? Send for Neuro ophthalmology consult Report says: вЂњPt has normal visual acuity, bilateral cataracts and otherwise normal ocular health. A Vis field was unable to be completed due to poor cooperationвЂ¦ and she s/p R fronto-parietal meningiomaвЂќ. 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 вЂњmiss thingsвЂќ on R side Difficulty reaching accurately for objects in front of him What do you do? Ophthalmology consult Report: вЂњpt 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.вЂќ Does that help you determine a treatment plan for this patient? The Three OвЂ™s Ophthalmologist вЂ“ Eye surgeon вЂў вЂў Neuro-ophthalmolgy (where is the lesion) Medical/surgical diagnosis and treatment of neurological disorders Optometrist вЂ“ evaluation, diagnosis, and treatment of the functions of the visual systems The Three OвЂ™s вЂў Neuro Optometry/Neuro Optometric Rehabilitation (<1% of profession) пЃ® вЂў Neuro optometrist should be part of the rehab team (whenever possible) Optician вЂ“ makes and dispenses eyewear вЂў Non-medical professionals пЃ® Vision Rehabilitation: Neuro-Optometric (NOR) пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® 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 ADLвЂ™s NOR Therapy / Management Lenses вЂ“ non-compensatory (near, far, astigmatism) Prisms вЂ“ 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) пЃ® пЃ® Visual Processing Following Brain Injury 79% of brain injured individuals in one study had strabismus with diplopia (Mitchell, MacFarlane, and Cornell) пЃ® Visual Processing Following Brain Injury пЃ® 20% of all stroke patients in their study suffered from some sort of visual problem (Samo and Samo) пЃ® пЃ® Visual Processing Following Brain Injury 59% of brain injured patients in their study displayed visual problems (Schlageter, Gray, Hall, Shay, and Sammet) пЃ® пЃ® Visual Processing Following Brain Injury 60% of stroke patients had unilateral neglect (Adams and Hurwitz) пЃ® пЃ® 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) пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Studies are widely varied Depends on the pt population Depends how you classify вЂњvision problemsвЂќ вЂў вЂў вЂў вЂў Tracking? Attention? Spatial judgment? Sensory changes? PatientвЂ™s perception of vision problems Distance and near вЂњsightвЂќ. Clarity only пЃ® They may have VF loss or significant perceptual changes, but may deny having visual problems пЃ® The eyes are for seeingвЂ¦ пЃ® More than 30% of the human cortex is devoted to vision and visual processing connections with non-visual systems. пЃ® пЃ® пЃ® The eyes are for seeingвЂ¦ 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 вЂњnon visualвЂќ cortical areas more commonly associated with balance, emotion and memory. пЃ® Why is NOR required? пЃ® 80% of the brain is connected to visual processing пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® 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: пЃ® Vision Problems Encountered Medical Problems Encountered: Dry eyes Glaucoma Cataracts Diabetic Retinopathy Macular Degeneration Vascular Occlusive Disease Other Retinal Degenerative Diseases Sight Problems Encountered пЃ® Sight вЂў вЂў вЂў вЂў вЂў Acuity Contrast Sensitivity Color Vision Glare Sensitivity Visual Field пЃ® Functional Vision Problems Encountered пЃ® Ocular-Motor Problems вЂў вЂў вЂў вЂў вЂў вЂў вЂў Fixation Pursuits Saccades Nystagmus Vestibular-Ocular Reflex Pupils Accommodation пЃ® Functional Vision Problems Encountered пЃ® Visual Processing Problems вЂў Visual-Motor-Integration Skills вЂ“ Handwriting вЂ“ Reach & Grab вЂ“ Ambulating вЂ“ Driving пЃ® Functional Vision Problems Encountered пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Visual Processing Problems вЂў Visual-Analysis Skills вЂ“ Visual Discrimination вЂ“ Visual Closure вЂ“ Visual Form Constancy вЂ“ Visual Figure Ground вЂ“ Visual-Spatial Relations вЂ“ Visual Memory вЂ“ ExamplesвЂ¦. Visual Discrimination Visual Closure Visual Form Constancy Visual Figure Ground Visual Spatial Relations Visual Memory Visual Memory пЃ® Functional Vision Problems Encountered пЃ® Visual Processing Problems вЂў вЂў вЂў VisualвЂ“Motor Integration Skills Visual Analysis Skills Visual-Spatial Skills вЂ“ Visual Midline вЂ“ Unilateral Spatial Inattention (Neglect) вЂ“ Visual Multitasking пЃ® вЂў вЂў вЂў вЂў вЂў вЂў вЂў пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Visual Spatial Problems THE MAJORS вЂњThe Dangerous OnesвЂќ 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 пЃ® THE MAJORS вЂњThe Dangerous OnesвЂќ вЂњThe Disabling OnesвЂќ 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. вЂў вЂў вЂў вЂў вЂў Ocular Trauma Cranial Nerve Palsy (3rd, 4th, 6th) Supranuclear Palsy Decompensation Visual-Spatial Dysfunction пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Diplopia Not always reported by patient. вЂў May claim вЂњblurry visionвЂќ 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 workвЂ¦ Try selective occlusion Therapy Activities for Eye Teaming Brock String Vectograms Aperture Rule Computerized activities пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® START BY ENSURING MONOCUALR SKILLS ARE EQUAL! Tranaglyphs and Vectograms Aperture Rule Computerized activities Visual Field Defects Unilateral вЂў вЂў Central scotoma Paracentralscotoma Superior and Inferior Concentric Homonymous Hemianopsia Unilateral Spatial Inattention (Neglect) Homonymous Hemianopsia Bump into objects on one side CanвЂ™t find objects on one side of the room Says they canвЂ™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 пЃ® пЃ® Pre VRT Post VRT пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® 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 вЂњNeglectвЂќ: 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 CanвЂ™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 DoesnвЂ™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 вЂњIвЂ™m finished shavingвЂќ пЃ® 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 пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Key is an unawareness or denial of the USI Draw a Clock вЂ“ 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 пЃ® THE MAJORS вЂњThe Dangerous OnesвЂќ вЂў вЂў вЂў Diplopia Visual Field Defects Unilateral Spatial Inattention (Neglect) пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® вЂў вЂў вЂў Visual Midline Shift Syndrome Post-Traumatic Vision Syndrome Visual Multitasking Dysfunction Visual Information Processing Two separate processes вЂў вЂў 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 вЂў вЂў вЂў вЂў 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: вЂў вЂў kinesthetic proprioceptive пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® вЂў вЂў 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 вЂў вЂў вЂў вЂў Dizziness or nausea вЂ“ (balance, coordination, and posture) Spatial disorientation Leaning forward / backward / one side Other associated Neuro-motor difficulties Visual Midline Shift Syndrome (VMSS) Common Characteristics вЂў вЂў вЂў вЂў вЂў 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 пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Post Trauma Vision Syndrome (PTVS) Common Characteristics вЂў вЂў вЂў вЂў exotropia / exophoria (eyes turned out) convergence insufficiency accommodative insufficiency ocular motor dysfunction Post Trauma Vision Syndrome (PTVS) Common Characteristics вЂў вЂў вЂў вЂў вЂў 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 вЂў вЂў вЂў вЂў вЂў Diplopia Blurred or hazy vision--ghost images Inappropriate motion sensation, dizziness, nausea Headache, especially when reading Glare or light sensitivity пЃ® пЃ® Post Trauma Vision Syndrome (PTVS) Common Symptoms вЂў вЂў вЂў Headache with light exposure (photophobia) Dry eye syndrome Reading problems вЂ“ including unstable focusing, poor line tracking, losing place in text, poor comprehension and memory of text пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® PTVS is common in mild TBI Why arenвЂ™t mild TBIвЂ™s picked up on MRI? MRI is вЂњmacroвЂќ scale вЂ“ Вј mm best resolution Cell level is 1/1000th of mm Damage within a neuron = 1/1millionth of mm How much force does it take вЂ¦ Head laceration/bruising? пЃ® 300-400 lbs of pressure To break a car window? пЃ® 500-700 lbs of pressure To crush skull? пЃ® 1000 lbs of pressure Visual Multitasking Simultaneous Central / Peripheral Visual Processing вЂў 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 вЂњtubular-visionвЂќ approach, sequentially looking at one thing at a time. пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Significantly slows вЂњSpeed of ProcessingвЂќ down Visual Multitasking Dysfunction Anxious in crowds Difficulty shopping вЂў вЂў Overwhelmed by too much stuff Gets lost easily in store Driving is dangerous вЂў вЂў Poor lane maintenance Anxious with increased traffic and speed, or night driving Dizziness Dizziness вЂ“ 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 вЂў Move head back/forth look for drop in VA Grade dizziness level sitting, standing moving, environment moving, turning VOR response вЂў Thrust head to one side while looking at you Egocentric localization вЂў Point nose at my nose, or at specific object Treatment Selective occlusion пЃ® пЃ® пЃ® пЃ® пЃ® вЂў вЂў вЂў Binasal вЂ“ Decreases peripheral processing load to enable hypo-thalamic tract function Bitemporal вЂ“ works with long standing exofusional difficulties Sectoral вЂ“ as needed Binsalocclussion Treatment Filters вЂў Glare = disorganized light вЂ“ Polarization вЂ“ organizes light in straight lines to reduce glare вЂ“ Tints вЂ“ reduce the total amt of light вЂ“ Gradient вЂ“ darker on top вЂ“ Transition вЂ“ change with light exposure вЂ“ Combinations Treatment Vision therapy вЂў вЂў вЂў вЂў вЂў пЃ® Eye movement вЂ“ must be SLOW and in developmentally correct order вЂ“ vertical, horizontal, rotational, then diagonal Vestibular (root of eye movements) Vergence ranges (range of motion for VOR) Awareness вЂ“ peripheral awareness stationary/mobile Ambulation Infinity Walk пЃ® Arousal, Attention and Modulation пЃ® Basic Activities вЂў вЂў вЂў пЃ® пЃ® Turn and Clap Turn and Catch Treatment Syntonic Light Therapy вЂў вЂў пЃ® пЃ® Turn and Touch Applied use of specific wavelengths to the eyes for specific changes to blood chemistry (affecting endocrine) Started in the 1900вЂ™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) пЃ® 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) пЃ® пЃ® 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) пЃ® Visual processing gains through therapy are maintained a year after discharge (Weinberg et al) пЃ® What is Vision Therapy? вЂњвЂ¦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.вЂќ Advanced Therapist Vol. 34, Number 1, p. 131 пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® Locating a Doctor To locate a Neuro-Optometric Rehabilitation Specialist вЂў вЂў вЂў вЂў вЂў www.covd.org vision development www.nora.ccneuro rehabilitation firstname.lastname@example.org Merrimackvision.com Eyeqvisiontherapy.com For More Information www.merrimackvision.com www.nora.cc www.covd.org пЃ® Kevin M. Chauvette, O.D., FCOVD (603)424-0404 Merrimack, NH (603)644-6100 Manchester, NH email@example.com пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® References  Padula WV, Shapiro JB, Jason P. Head injury causing post trauma vision syndrome. New England Journal of Optometry 1988;41(2):16вЂ“21.  Schlageter K, Gray B, Hall K, et al. Incidence and treatment of visual dysfunction in traumatic brain injuries. Brain Inj 1993;7:439вЂ“48.  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):8979вЂ“89.  Klemm WR. Understanding neuroscience. St. Louis (MO): Mosby; 1996. p. 101вЂ“52.  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. 1вЂ“28. пЃ® пЃ® пЃ® пЃ® пЃ® пЃ® пЃ®  Van Gelder RN, Wee R, Lee JA, et al. Reduced pupillary light responses in mice lacking cryptochromes. Science 2003;299(5604):222 пЃ® References  Van Gelder RN, Wee R, Lee JA, et al. Reduced pupillary light responses in mice lacking cryptochromes. Science 2003;299(5604):222.  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):6405вЂ“12.  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):4вЂ“5.  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):261вЂ“7.  Moseley MJ, Bayliss SC, Fielder AR. Light transmission through the human eyelid: in vivo measurement. Ophthalmic Physiol Opt 1988;8(2):229вЂ“30.  Zelinsky. Rehabilitation. Phys Med RehabilClin N Am. 18 (2007) 87вЂ“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 вЂњVвЂќ or вЂњXвЂќ 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 вЂњXвЂќ should immediately be seen with the center of the вЂњXвЂќ 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: п‚· п‚· п‚· 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 вЂњnoвЂќ. 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 patientвЂ™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 patientвЂ™s eyes closed. Rotation should be in the direction of the gaze preference (if eyes are вЂњstuck to leftвЂќ 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 patientвЂ™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 patientвЂ™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 patientвЂ™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 patientвЂ™s normal field and abnormal filed with penlight held approximately 20 degrees to patientвЂ™s temporal side. Patient is instructed to quickly move their eyes to look at the light that is turned on. Even in patientвЂ™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 вЂњthrowingвЂќ 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 вЂњpairsвЂќ 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 patientвЂ™s own best score from prior days as an incentive to improve their processing speed.