Occupational Therapy & Vision Rehabilitation

1. Occupational Therapy & Vision Rehabilitation Presented by: Margaret A. Waskiewicz MS, OTR/L Unit Supervisor, Adult Outpatient OT Special acknowledgement: Christina Finn MS, OTR/L

2. Defining Vision • More than 20/20 • Ability to interpret and understand what we are seeing • “It is the total ability to organize light input and recognize spatial relationships between things and to build an internal representation of reality” (Paul Harris, 1998)

3. Diagnosis CVA/Stroke **TBI** Parkinson’s Disease Multiple Sclerosis Concussion

4. Common Vision Diagnoses • Homonymous Hemianopsia • Homonymous Quadrantonopsia • Optic Neuritis • Convergence Insufficiency

5. Common Visual Complaints • “I get tired when trying to read” • “When I turn too quickly I get dizzy” • “I feel like it is difficult to find things” • “I am seeing double” • “My vision is blurry” • “My depth is off” • “I am skipping lines when reading”

6. Impact on Functional Activities • Self-Care/ADL • Household/IADL • Reading/Computer/Work-Related Tasks • Community Mobility & Driving • Quality of Life

7. Occupational Therapy Evaluation & Vision Screen: What Do We Look At?

8. OT Evaluation: • Functional complaints • ADL: • Managing buttons/fasteners • Lower body self-care • Showering • IADL: • Community: • Grocery Shopping • Crossing the street • Navigating from home to destination • Household: • Cooking • Cleaning • Laundry • Paying bills/writing checks • Work Related Tasks • Writing, reading, computer use • Writing sample • Wold Sentence Copying • Reading sample • DEM, K-D Test • QOL: NFQ-25 **Consider quality and safety not just independent or not! • Physical Function • Basic AROM • Hand Eye Coordination: • 9 hole peg test • Purdue pegboard • Grip/Pinch • Qualitative observations about posture (head tilt, rotated head, tilted pelvis)

9. OT Vision Screen: • Basic Test of Near & Far Acuity • Oculomotor: • Pursuits • Saccades • Ocular ROM (monocular and binocular) • consider if symptoms are provoked • Binocular: • Convergence/Divergence • Brock String • Stereopsis • Worth 4 Dot for Suppression • Eye Alignment: • Phoriacards • Cover/Uncover Test • Visual Fields • Visual Perceptual Testing (LOTCA, Behavioral Inattention Test, MVPT)

10. Adaptations, Interventions & Treatment

11. Adaptations to Improve Comfort with Reading and Computer Use • Line Guide • Colored Tints • Anti-Glare screen • Reduce Glare • Ergonomics/Rest Breaks

12. Adaptations for Low Vision • Increase Contrast • Reduce Glare • Reduce Clutter • Assistive Technology: • Screen Readers • Screen Magnifiers • Large button keyboards

13. OT Treatment for Oculomotor Skills • Improving visual scanning/saccades • Improving smooth pursuits/tracking • Incorporate into functional activity Posture & use of body movements are all considered!

14. OT Treatment for Oculomotor Skills • Monocular/binocular strengthening • H, X, O • 4-corners • Clock • Post-its • Crossword Puzzle • Letter cancellation • Multi-matrix • Vision coach • Biometrics

15. Management of Double Vision/Binocular Impairments in OT • Compensation • Partial Occlusion • Teach eye teaming skills and how to use in a functional context • Integration of body movements with eye movements

16. Management of Double Vision/Binocular Impairments in OT • Pencil push-ups • Straw Piercing • Brock string • Thumb/Post-it • Static • Dynamic • With environmental distractions

17. Referrals for Vision Rehab • Appropriate Referrals • Concussion with saccadic impairment • Visual Disturbance • Diplopia • Visuospatial neglect • Concussion with convergence insufficiency • TBI with impaired saccades • Dizzy patient of unknown etiology with oculomotor impairments • Inappropriate Referrals • Strabismus for several years • Elderly patient with changes in vision (ie. accommodation) • Macular degeneration • Glaucoma • Cataracts

18. Who Is Involved? • Occupational Therapist • Neuro-ophthalmologist • Neuro-optometrist • Physiatrist • Other rehab services • PT • Vestibular PT • SLP • Neuropsychology/psychology • Nursing • Social work • Vocational rehab

19. Conclusion • The visual system allow us to make sense of our world and to be able to adapt to our ever changing environment. • Our vision is also involved in up to 85% of our perception, learning and mental acquisition of knowledge.

20. References • Brown, C., Tolefson, N., Dunn, W., Cromwell, R. & Filion, D. (2001). The adult sensory profile: measuring patterns of sensory processing. American Journal of Occupational Therapy, 55, 75-82. • Ciuffreda, K.J., Kapoor, N., Rutner, D., Sucholf, I.B., Han, M.E., & Craig, S. Occurrence of oculomotor dysfunctions in acquired brain injury: A retrospective analysis (2007) • Goodrich, G.L., Flyg, H.M.,Kirby, J.E., Chea-Yo Chang, C., Martinsen, G.L. (2013). Mechanisms of TBI and Visual Consequences in Military and Veteran Populations. Optometry and Vision Science, 90, 105-112. • Khan, F., Baguley, I.J., & Cameron, I.D. (2003). Rehabilitation after traumatic brain injury. MJA Practice Essentials, 178, 290-295.