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