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Visual and Perceptual Deficits After a Neurological Event
Stacy Krueger, OTR/L, C/NDT 2016
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Why is Vision Important?
Vision plays a vital role in all activities of daily living Visual deficits are often overlooked
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Three Component Model of Vision
Visual Integrity Visual Efficiency Visual Information Processing
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Visual Integrity Visual Acuity, Refraction, and Eye Heath
Visual Acuity (i.e., 20/20) Numerator- testing distance at which the subject recognizes stimulus Denominator- Distance at which the letter being viewed could be identified by a patient with normal visual acuity
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Visual Integrity Visual Acuity, Refraction, and Eye Heath
Refraction- The optical system of the eye Emmetropia (without refraction error) Myopic (nearsighted) Hyperopic (farsighted) Astigmatism
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Refraction Errors
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Visual Integrity Visual Acuity, Refraction, and Eye Heath Eye Heath-
Anterior segment, lens, posterior segment, visual pathway
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Eye Health Disorders Low Vision: 20/70 or worse with best correction
Anterior Segment Diseases Ptosis, Inflammations, Corneal Scar
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Eye Health Disorders Diseases of the Lens Cataracts
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Vision with Cataracts
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Eye Health Disorders Posterior Segment Diseases
Glaucoma, Diabetic Retinopathy, Age Related Macular Degeneration
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Diabetic Retinopathy
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Age Related Macular Degeneration
Leading cause of blindness in those older than 65 years Dry Macular Degeneration- 20/20 to 20/400 Wet Macular Degeneration- worse than 20/400
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Visual Pathways
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Vision Changes after an Injury
The location of damage caused by a stroke or brain injury will determine the different visual changes. Each eye receives some of the information from each half of the environment. The information or image from each eye is combined, crosses over in the middle of the brain, and is then carried to the occipital lobes. If you have a stroke on the right side of your brain, it primarily affects the vision on the left. A stroke on the left side of the brain affects the vision on the right.
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Visual Field Cut (Hemianopsia)
Visual Field is everything you see when your both eyes are open. Visual field cut (i.e., hemianopsia) is the inability to see part of the visual field The most common loss of vision is the ability to see on one side (peripheral vision) or loss of half the visual field of each eye. Visual field loss may take a long time to improve or may be permanent.
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Visual Field Cuts
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Visual Field Cuts
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Visual Field Cuts
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Visual Efficiency Effectiveness of the Visual System to clearly, efficiently, and comfortably allow someone to gather visual information Accommodation (i.e., focusing) Binocular Vision (i.e., eye muscles and teaming) Eye Movements (i.e., tracking)
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Accommodation Disorders
Insufficiencies – Lens hardens, neuromuscular pathway problems Excess – Muscles can not relax Symptoms: Blurred Vision Headaches Eyestrain Avoidance of reading or other close work
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Binocular Vision The brainstem helps control eye movement. It directs the six muscles that keep the eyes moving together as you look up, down, right, and left.
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Binocular Vision Disorders
Muscle weakness or Paralysis Convergence Insufficiency
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Binocular Vision Disorders
Strabismus- When two eyes lose alignment
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Binocular Vision Disorders
Diplopia (i.e., Double Vision) Common if the stroke or brain injury affects the cerebellum or brainstem
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Eye Movements Fixation Saccades- (i.e., scanning)
Pursuits (i.e., tracking)
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Eye Movement Disorders
Nystagmus Visual Scanning Problems- decreased accuracy and speed Visual Tracking Problems- unable to accuracy follow objects Can affect a person from returning to activities of daily living including self care, reading, and driving
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Visual Information Processing
This is where the true "seeing" takes place. Taking in and organizing visual information from the environment Integrating this visual information Making a motor response
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Visual Information Processing
Visual spatial skills Used to interact the environment Develop directional awareness Develop good motor coordination and balance
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Visual Spatial Dysfunction
Lack of coordination and balance Clumsy, falls Tendency to work with one side of the body Reversing letters and numbers
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Visual Information Processing
Visual Perception The ability to interpret the surrounding environment by processing information that is contained in visible light.
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Visual Perception Visual Discrimination- size, shape, orientation
Figure Ground- attending to a form while maintaining awareness of background Visual Closure- determine final picture without all the pieces Visual Memory- recognize and recall visually presented information
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Visual Perceptual Hierarchy
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Visual Processing Deficits
Common Visual Processing Deficits include: Visual inattention Visual neglect Decreased speed of visual and cognitive processing
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Visual Inattention The inability to perceive a stimulus in a visual field when a similar stimulus is presented and perceived simultaneously in the same visual field Most evident when searching for visual detail when array is complex and random
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Visual Neglect Most severe form of visual inattention
Hemispatial neglect is a deficit in attention to and awareness of one side of space is observed. It is the inability of a person to process and perceive stimuli on one side of the body or environment A person with left neglect may hold their head or eyes to the right may not look at you if you stand to their left may not be able to locate items on the left may run into objects on their left side
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Visual Neglect Presentation of a person with left neglect may include:
hold their head or eyes to the right may not look at you if you stand to their left may not be able to locate items on the left may run into objects on their left side
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Visual Neglect
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Speed of Visual Processing
People who sustain a neurological event often have decreased speed of visual processing Functional scanning and processing speed is necessary for returning to competitive employment, school activities, and driving
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Visual Motor Coordination
Ability to integrate visual information processing skills with: Fine motor coordination Visual motor integration
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Visual Motor Dysfunction
Common symptoms with visual motor dysfunction: Fumbling objects Overshooting and undershooting Difficulty writing Slowed reaction times
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What Can We Do? Assessment for and identify potential visual deficits
Direct your patient to the appropriate professional Create functional goals for Visual Deficits Provide treatment activities to retrain visual skills and/or teach ways to help compensate for vision deficits
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Assessing for Visual Deficits
Clinical Observation Look at functional vision during ADL completion Bump into objects during ambulation Overshoot/Undershoot when reaching for items Miss items unilaterally Squinting when looking at targets
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Assessing for Visual Deficits
Interview Does the patient report any visual changes? Blurry or fuzzy vision Visual Fatigue Visual Fluctuations Missing items
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Assessing for Visual Deficits
Screening Complete simple oculomotor screening Fixation Saccades Pursuits Convergence
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Assessing for Visual Deficits
Screening Complete screening for visual tracking, attention, and neglect Letter Cancellation Shape Cancellation Line Bisection Draw Clock
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Letter Cancellation Task
Look at: Accuracy (Percentage correct) Scanning pattern (organized/disorganized) Pattern for missed targets (all on one side or scattered)
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Assessing for Visual Deficits
Complete standardized assessments Visual Perception Motor Free Visual Perceptual Test (MVPT) Speed of Visual Processing Trail Making Part A and Part B Visual Motor Coordination Dynavision D2
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Dynavision D2 The Dynavision D2 Visuomotor Training System has proven effective for use in visual, cognitive, and physical rehabilitation. The programmable options standard with Dynavision D2 software will enable the clinician to facilitate individualized treatment for clients of different ages, abilities, and conditions. Performance data is quantitative and objective ensuring accuracy for initial evaluation and progress monitoring.
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Dynavision D2
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Treatment for Visual Deficits
Small Scale: Cancellation tasks (letter, number, object) Following picture models (block design, dot design) Information seeking (store advertisement, using printed material, Computer)
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Treatment for Visual Deficits
Medium Scale: Matching and sorting activities Locate target objects (Cards on table, target positions/pieces on game board)
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Treatment for Visual Deficits
Large Scale: Dynavision D2 activities Visual Scanning during ambulation (i.e., Scavenger hunt) Kinect Wii Active Passenger Tasks
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Case Study “Mary” Complaint of blurred vision and difficulty with computer usage at work. Went to the eye doctor who sent her for additional testing due to concerns of Stroke in December
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Initial Visual Field Test
Left Eye Right Eye
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Evaluation Patient is unable to complete daily activities due to visual deficits (i.e., working, driving, cooking) Evaluation results include Impaired visual scanning, processing, perception Unable to read standard print or complete computer work Dynavison D2 60-second trial Score: 50 Average Reaction Time 1.20 seconds Intact UE and LE skills
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Treatment Treatment included:
Recommend Skilled OT 3x/week which tapered to 2x/week as patient progressed Completed 44 treatment session prior to discharge Treatment included: Training for functional visual scanning patterns Activities to improve perceptual skills Information seeking using printed material and computer tasks Dynavision D2 to improve visual motor coordination and speed of visual processing
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Repeat Visual Field Test
Left Eye Right Eye
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Discharge Mary did have some continued visual deficits, however was able to compensate well enough to return to independent living and driving. Discharge Dynavision D2 60 second trial Score: 78 Average Reaction Time: 0.77 seconds
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Questions?
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References Ciuffreda KJ, Suchoff IB, Marrone MA, Ahmann E., Oculomotor rehabilitation in traumatic brain-injured patients. J Behavioral Optom 1996; 7:31-38 Scheiman M, Gallaway MF., Vision Therapy to Treat Binocular Vision Disorders After Acquired Brain Injury: Factors Affecting Prognosis. In: Suchoff I, Ciuffreda, KJ, Kapoor N, ed. Visual and Vestibular Consequences of Acquired Brain Injury. Santa Ana: Optometric Extension Program; 2001 Suter, P., Harvey L., Vision Rehabilitation: Multidisciplinary Care of the Patient Following Brain Injury, CRC Press, New York, 2011 Schlageter K, Shaw R., Vision Therapy. OT Week, July 11, 1991. Warren, M.L. (1993). “A Hierarchical Model for Evaluation and Treatment of Visual Perception Dysfunction in Adult Acquired Brain Injury” Parts 1 and 2, American J of Occupational Therapy, 47:42-66
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