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Oculomotor & Visual Perceptual A & I Cheat Sheet by

Oculomotor & Visual Perceptual Assessment & Intervention

Vision Assessment Overview

Vision Assessment Overview

Binocular Coordi­nation requires effective…
Smooth pursui­ts/­tra­cking Saccades Conver­gence Divergence Stereo­psi­s/S­patial locali­zation Focal and Ambient Visual Proces­sing- Physio­logical diplopia
Binocular Dysfun­ctions due to BI may results in…
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

Eye Alignment: Phoria

Natural positi­oning of the eye (everyone has phoria)
Tendency is to aim in front (esoph­oria) or behind (exoph­oria) the point of focus (conve­rgence)
Fusion is intact
Depth perception may be intact
Measured by prism diopters
Produce subtle symptoms
difficulty concen­tra­ting; frontal or temporal headaches; sleepiness or stinging of eyes after reading

Eye Alignment: Strabismus or Tropia

Visible turn of one eye (constant, interm­ittent, altern­ating between both eyes)
Esotropia: One eye turns in; Exotropia: One eye turns out; Hypert­ropia: One eye turns up relative to other eye
Fusion (binocular vision) and depth perception (stere­opsis) are not present

Strabismus or Tropia


Oculomotor N. Palsy

Paralysis of the SR, MR, IR, IO
Diplopia; Extrao­cular weakness resulting in exotropia; Conver­gence insuff­ici­ency; Ptosis­-upper eyelid droops; Photos­ens­itivity (if ciliary ganglion affected); Accomm­odation insuff­iciency (if ciliary ganglion affected)

Oculomotor N. Palsy

Trochlear N. Palsy (CN IV)

Superior Oblique M. paralysis of the contra­lateral eye
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

Trochlear N. Palsy (CN IV)

Abducens N. Palsy (CN VI)

Lateral Rectus M. paralysis
Unable to move eye into abduction or laterally toward temporal field of the ipsila­teral eye
Diplopia with temporal gaze
Divergence Insuff­iciency

Abducens N. Palsy (CN VI)

Oculomotor Control Testing (Volun­tary)

Smooth pursui­ts/­tra­cking
Patient should follow target with eyes in a “T” then “X” pattern
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.
Pencil push up; Brock String
Brock String

Brock String

Used to train conver­gence and divergence
improves fusion of the eyes and increase peripheral awareness (physi­olo­gical diplopia)
Can be fatiguing for indivi­duals with diplopia or impaired visual processing
Can be challe­nging to understand for individual with cognitive of memory impair­ments
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)


Long-term effects result in central vision suppre­ssion
peripheral vision remains intact
Cover or close one eye OR favor one eye over the other
Under/over reaching objects
Double vision
Under/over reaching objects
Avoid near activities
Exhibit head tilt or turning during activities

Oculomotor Interv­entions

SEE Exercises
Pacing Programs (Funct­ional Activity Logs)
Brock String
Binasal Occlusion
Field Expansion (central peripheral awareness)
Accomm­odative Flippers
Comput­er-­based activities

Computer Based Vision Therapy

Great for people with good attention for sustained period of time and decent cognition (e.g., mild TBI)
Can be very fatiguing
Advanced vision therapy option for higher level goals such as driving or return to work
Great for individual who like objective measur­ements and goals
May be challe­nging for more severe BI
Great for “gamers”
Seizure contra­ind­ica­tions
Ex: Sanet Vision Integr­ator, Vision­Bui­lder, Bernell, Youtube

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 bed time story to your kiddos
- 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

Don’t Over Do it!

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
Establish a baseline: determine length of time an activity occurred resulting in onset of symptoms
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)
Establish a “Pacing” Plan: termin­ating or pausing an activity prior to onset of symptoms; then resuming activity after symptoms subside

Unders­tanding Yoked Prisms

Deviates an images toward its apex
Eye must also turn toward the apex of the prism in order to remain aligned with the image
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
allows the eye to rotate to a more comfor­table position, while still remaining aligned with the image

Pacing Programs

Many indivi­duals with Mild TBI push themselves beyond a point of recovery, which often can leave them “helpless” for hours or even days
Create a “funct­ional activities log” or “pacing program”
- 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.)

Peripheral Central Awareness Activities

Increasing awareness of physio­logical diplopia and peripheral fields

How do prisms help?

Shifting the image allows for increased comfort improving eye fusion
increases of expands peripheral awareness improving visual field loss and ambient visual processing
Diplopia may be eliminated
Alters the persons perception of reality improving midline shifts
Typically used in conjun­ction with vision therapy and functional activities
Can treat visual dysfun­ctions while elimin­ating need for patching an eye (monocular vision)
Should only be completed with recomm­end­ations supplied by neuro-­opt­ome­trist

Occlusion Strategies Images

Other Occlusion Strategies

Central Taping Occlusion
- Occluding central vision to reduce diplopia
- Complete occlusion of non-do­minant eye
Pros: Benefits allowing peripheral vision processing to remain exposed to sensory feedback
- Ideally altern­ating patch to eliminate risk of suppre­ssion
Cons: May be visually distra­cting for patients who have additional cognit­ive­/pe­rce­ptual dysfun­ctions
- Altern­ating schedules are dependent of patient's tolerance (phoria vs tropia)
Pros: allows for immediate relief of double vision
Cons: Utilizing monocular vision only can result in suppre­ssion due to no sensory feedback in non-used or affected eye

Why try binasal occlusion?

Binasal Occlusion is a non-in­vasive method and is easy to apply in patients with mTBI and motion sensit­ivity
Reduces the symptoms caused by increased motion sensit­ivity and double vision
Provides immediate and sustai­nable effects by reducing stress with visual processing
May enhance perfor­mance during activities of daily living, hobbies, and work related activities

Field Expansion (Perip­heral Central Awareness)

Goal is to strengthen the peripheral field awareness (ambient proces­sing) while engaging in central vision activities resulting in field expansion
This strategy improves gaze stabil­ization which improves reading skills, identi­fying obstacles quickly and effici­ently, and improve antici­patory response time to reduce risk of falling
Must have adequate attention, arousal, and cognitive function to succes­sfully use this strategy

Type of Visual Field Testing

Kinetic Confro­ntation (behind person)
Confro­ntation Field Testing (in front of person)

Functional Observ­ations of Visual Field Deficits

Collides of comes very close to obstacles on one side in an unfamiliar enviro­nment
Stares straight ahead at the floor immedi­ately in front of them
Consis­tently stares to one side
Uses finger to “trail” wall to guide self
Refuses to take the lead when ambula­ting, preferring to walk behind others
Anxious or uncertain in crowded areas
Stops walking when approa­ching or passing by another moving person or object
Complains of feeling off balance partic­ularly to one side

Visual Pathway Lesions

Visual Pathway Lesions: loss of visual fields

1. Right Eye Anopsi­a/B­lin­dness
2. Bitemporal hetero­nymous hemian­opsia
3. Binasal hetero­nymous hemian­opsia
4 & 5. Contra­lateral homonymous hemian­opsia
6. Contra­lateral upper quadrant anopsia
7. Contra­lateral homonymous hemian­opsia with macular sparing

Diminished or Lost Visual Field Strategies

Increase awareness to affected visual field through adaptation
- Visual scanning to affected side requiring head turning to scan surrou­ndings
- Visual aides or markers to ensure the individual know how far to scan
- Position self on the side of affected visual field when looking far away (i.e. during a presen­tation, movie theater, etc.)
- Have someone walk on the side of the affected visual field
Prism lens may help with visual field expansion as prescribed by neuro-­opt­ome­trist
Central peripheral Expansion?

Spatial Locali­zation

Judgement of space and distance- Stereopsis (depth percep­tion)
Functional observ­ations that can impact safety
Can be affected by…
- Difficulty negoti­ating steps, stairs, or curbs or safely navigating around enviro­nmental obstacles
- Changes in acuity
- Pouring hot coffee without spilling or reaching for skillet handle on stove top without burning self
- Contrast sensit­ivity
- 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
- Poor integr­ation of focal and ambient visual processing systems
- Divergence and/or conver­gence insuff­ici­encies (binocular vision dysfun­ctions)

Stereopsis Testing

Finger to nose test
The Randot Stereotest

Visual Perceptual Testing


Visual Perceptual Strategies

Scanning strategies
Task Analysis
External Cues (e.g. Increasing Contrast)
Cognitive strategies
Oculomotor Exercises

Visual Perceptual Activities

Functional Activities
Therapy activities
Dressing with or without AE
Applying make-up
Grocery shopping
Organizing spice rack and or pantry
Organizing groceries to put away
“Where’s Waldo?”
Sorting and organizing dishes from the dishwasher
Sorting and folding laundry
Line or design completion
Setting the table
Any activity involving constr­uct­ional praxis (e.g., 3-D building tasks)
Organizing medica­tions
Navigating Apps on phone or web browsers


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