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
Hypertropia
Hypotropia
Esotropia
Oculomotor N. Palsy
Paralysis of the SR, MR, IR, IO |
Symptoms |
Diplopia; Extraocular weakness resulting in exotropia; Convergence insufficiency; Ptosis-upper eyelid droops; Photosensitivity (if ciliary ganglion affected); Accommodation insufficiency (if ciliary ganglion affected) |
Trochlear N. Palsy (CN IV)
Superior Oblique M. paralysis of the contralateral eye |
Symptoms |
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 |
Symptoms |
Unable to move eye into abduction or laterally toward temporal field of the ipsilateral eye |
Diplopia with temporal gaze |
Divergence Insufficiency |
Esotropic |
Abducens N. Palsy (CN VI)
Oculomotor Control Testing (Voluntary)
Smooth pursuits/tracking |
Patient should follow target with eyes in a “T” then “X” pattern |
Saccades |
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. |
Convergence |
Pencil push up; Brock String |
Divergence |
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) |
Diplopia
Long-term effects result in central vision suppression |
peripheral vision remains intact |
Symptoms/signs |
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
Restoration |
Adaptation |
SEE Exercises |
Pacing Programs (Functional Activity Logs) |
Brock String |
Binasal Occlusion |
Field Expansion (central peripheral awareness) |
Prisms |
Accommodative Flippers |
Computer-based activities |
Computer Based Vision Therapy
PROS |
CONS |
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 |
Photosensitivity |
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 |
Patching |
- 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) |
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Pros: allows for immediate relief of double vision |
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Cons: Utilizing monocular vision only can result in suppression due to no sensory feedback in non-used or affected eye |
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 |
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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: 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 |
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- Divergence and/or convergence insufficiencies (binocular vision dysfunctions) |
Stereopsis Testing
OT TESTING |
Finger to nose test |
OPTOMETRIST TESTING |
The Randot Stereotest |
Visual Perceptual Testing
Visual Perceptual Strategies
Environment |
Person |
Occupation |
Organization |
Scanning strategies |
Task Analysis |
External Cues (e.g. Increasing Contrast) |
Cognitive strategies |
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Oculomotor Exercises |
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Visual Perceptual Activities
Functional Activities |
Therapy activities |
Dressing with or without AE |
Parquetry |
Applying make-up |
Puzzles |
Grocery shopping |
Tangrams |
Organizing spice rack and or pantry |
Mazes |
Organizing groceries to put away |
“Where’s Waldo?” |
Sorting and organizing dishes from the dishwasher |
Graphing |
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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