Navigating Visual Dysfunction: A Multifaceted Approach .
Navigating Visual Dysfunction:A Multifaceted Approach (Part 1)Marnie Deardorff, MS, OTR/LLaura Lizotte, MS, OTR/LLauren Mazel, OTD, OTR/LKara Robinson, MS, OTR/L
Disclosure Marnie Deardorff has no relevant financial or nonfinancialrelationships to disclose Laura Lizotte has no relevant financial or nonfinancialrelationships to disclose Lauren Mazel has no relevant financial or nonfinancialrelationships to disclose Kara Robinson has no relevant financial or nonfinancialrelationships to disclose
ObjectivesParticipants will be able to: Identify environmental modifications and compensatorystrategies for symptom management Identify common visual impairments associated withconcussion Identify effective screening and evaluation procedures forvisual dysfunction associated with concussion Identify treatment strategies for visual dysfunction associatedwith concussion
Vision and the Brain 90% of sensory input comes from our vision Over 50% of our brain is directly or indirectly involved in visualprocesses Vision is used for: Executive functioningReading/Writing/DrivingSocial interactionsMotor controlPosture
Visual PathwayOptic NerveOptic ChiasmTemporal lobeLateral GeniculateOccipital lobeCerebellum(Ventral Stream) Superior ColliculusParietal lobe(Dorsal Stream)
Visual ProcessingDorsal Stream THE WHERE spatial orientation, balance,posture, spatial mappingVentral Stream THE WHAT object and visual identificationand recognition
Cranial Nerves II: Optic sensory (Optic Nerve) III: Oculomotor Nerve Superior rectus (moves eyes up) Inferior rectus (moves eyes down) Medial rectus (moves eyes in) *convergence Inferior oblique's (moves eye out and up) Pupil lens and lid IV: Trochlear Motor Superior oblique (moves eye in and down) VI: Abducens Motor lateral rectus (abducts eye)(westerneye.com)
Treatment ApproachSymptomManagementReturn kModification
Treatment DomainsSymptom Management / ModificationsOcular Motor SkillsBinocular VisionAccommodation (“Focusing Ability”)Visual Processing SkillsFunctional Training
Treatment DomainsSymptom Management /ModificationsOcular Motor SkillsBinocular VisionAccommodation (“Focusing Ability”)Visual Processing SkillsFunctional Training
Concussion Symptoms Headaches Dizziness Nausea/Vomiting Eye strain Light sensitivity Double vision Blurry vision Noise sensitivity Tinnitus Sleep disturbance Mood disturbance Balance deficits Impaired coordination Fatigue Brain fog Cognitive deficits Memory Executive function Attention
Concussion SymptomsVideo
Symptom Management General guidelines Addressing light, screen, contrastsensitivity Task modification / Adapted techniques Additional strategies and education Community reintegration
General Guidelines Maintaining function and quality of life with guidelines and limits Understanding triggers Graded return approach The more acute the injury, the moreconservative the approach The patients who “do nothing” seem to get stuck
General GuidelinesVideo
General Guidelines Symptom Tracking within Activities Reading Date: 6/220 minutes 4/10 Headache; 3/10 Eye strain Date: 6/515 minutes 2/10 Headache; 2/10 Eye strain Computer Use Date: 8/1020 minutes 6/10 Headache; 5/10 Eye strain Date: 8/125 minutes 3/10 Headache; 3/10 Eye strain
General GuidelinesVideo
Addressing Light, Screen andContrast Sensitivity
Addressing Light, Screen andContrast Sensitivity
Light Sensitivity Management The amount of light that a person lives in will effect symptoms. Ifone lives in darkness all of the time, then light will be sensed asbeing even brighter. Graded return approach Use of color tinted glasses, blue light blocking glasses, colorfilters for reading and computer use, screen brightness softwareand filters, side or back lighting, overhead light covers
Addressing Light, Screen andContrast Sensitivity
Addressing Light, Screen andContrast Sensitivity iPhone/Andriod “display accommodations”Reduced white pointColor filters/lensNightshift/blue light filter Internal settingsVoice dictationEnlarged fontText-to-SpeechReduced motion
Addressing Light, Screen andContrast SensitivityColor filtersColor paper
Task Modification - Reading Color filters Tinted glasses Blocking strategies Visual cues/line guides Enlarged font /content Print material on colored paper Change position of material Audiobooks; text to speech
Task Modification - Computer Contrast and brightness settings Anti-glare filters / Colored filters / TintingSoftware Tinted lenses Changing background color / Shading options Changing font size and color Enlarging icons and curser Voice-to-text / text-to-speech software Printing material to read on paper Line guide software Using a projector Positioning of screen / position of material
Google Docs – blue setting
Apple “reader o-use-and-tweak-reader-modein-safari/
Modification Guidelines Individualized strategies Graded return approach to buildingtolerance with modifications Fading use of modifications as toleranceimproves
Additional Education andStrategies Use of heat/ice for symptommanagement
Additional Education andStrategiesStress management andrelaxation strategiesLAURENMeditation apps Insight Timer Headspace Calm Sounds TrueProper sleephygiene
Recovery is NOT LinearVideo
Community Reintegration
Community Reintegration Shopping at off hours Use hat/visors Use sunglasses/tinted glasses Use ear plugs Have an exit strategy/plan Position of selfAt restaurant seating facing wallAt a party leaning against a wall Know the environmentShopping at a familiar store decreasesneed to scan for items
Treatment DomainsSymptom Management / ModificationsOcular Motor SkillsBinocular VisionAccommodation (“Focusing Ability”)Visual Processing SkillsFunctional Training
Ocular Motor SkillsFixationSmoothPursuitsSaccades
Ocular Motor Dysfunction Loss of place or omission of words Poor endurance Excessive head movement Poor attention/distractibility Need for tactile/kinesthetic reinforcement Increased time to perform tasksUp to 65% present with ocular motor dysfunction(Collins et al, 2013)21-29% present with saccadic dysfunction(Gallaway et al. 2016)
Ocular Motor Skills - AssessmentSmooth Pursuits
Abnormal Smooth PursuitsVideo
Ocular Motor Skills - AssessmentHorizontal SaccadesVertical Saccades
Abnormal SaccadesVideo
Ocular Motor Skills – AssessmentKing Devick: Test of saccadic eye movementspeed and accuracy
Ocular Motor Skills- AssessmentKing Devick: Normal Video
Ocular Motor Skills- AssessmentKing Devick: Abnormal Video
Ocular Motor Skills- AssessmentVideoKing Devick Score:3 minutes 48 S (16 errors)Fail 57 S with maximum 1 error
The DEM Developed by Dr. Jack Richman, OD and Dr. Ralph Garzia, OD.
Ocular Motor Skills - TreatmentSaccades
Ocular Motor Skills - Treatment
Ocular Motor Skills - TreatmentPursuits
Ocular Motor Skills - TreatmentAnn ArborTracking Sheets
Ocular Motor Skills - Treatment
Ocular Motor Lab Assessment Fixation Smooth pursuits Saccades Horizontal Vertical
Treatment DomainsSymptom Management / ModificationsOcular Motor SkillsBinocular VisionAccommodation (“Focusing Ability”)Visual Processing SkillsFunctional Training
Binocular Vision Dysfunction Eye strain Frequent loss of place Headaches Squinting, rubbing eyes,closing one eye Blurred vision/double vision Poor concentration Words appear to move,jump, swim or float Sleepiness during task Motion sickness/ dizziness Head tilt or turn47-49% present with convergence insufficiency (Gallaway etal., 2016; Master et al. 2016)
nstitute.com(visiontherapy.com)
Binocular Vision Coordination of both eyestogether ‘Eye Alignment’ –Positioning of the eyes Convergence / Divergence –Functional ability (eyesmoving ads/TunnelV2.gif
Binocular VisionAlignmentTropia: Always presentPhoria: Present “some of the time”(strabismus)Cover / Uncover TestMaddox Rod / Phoria CardsAlternate Cover TestMaddox Rod / Phoria Cards
Binocular Vision - AssessmentDirection of misalignment
Binocular Vision - AssessmentCover/Uncover (Tropias)covAlternate Cover(Phorias)er (Tropias)Alternate Cover (Phorias)
Binocular Vision - AssessmentBinocular Vision : Alignment / ExophoriaVideo
Binocular Vision - AssessmentBinocular Vision : Alignment / EsophoriaVideo
Eye Alignment ScreeningNear Phoria CardMaddox Rod
Binocular Vision - AssessmentConvergenceNormal Break at4 inches (10cm)
Binocular Vision - AssessmentAbnormal ConvergenceVideo
Convergence InsufficiencySymptom Survey (CISS)American Optometric AssociationChildren ( age 21)total score 16 orhigher is suggestive ofconvergenceinsufficiencyAdults total score 21or higher is suggestiveof convergenceinsufficiency(Borsting, Rouse, Mitchel, et al and theCITT group)
Binocular Vision - Treatment“Pencil” Push UpVideo
Binocular Vision - TreatmentBrock String
Binocular Vision - TreatmentLifesaver Card
Binocular Vision - TreatmentAperture rule picture
Binocular Vision - Treatment
Binocular Vision LabPHYSIOLOGICAL es-the-brain/200906/you-see-it-is-it-real
Treatment DomainsSymptom Management / ModificationsOcular Motor SkillsBinocular VisionAccommodation(“Focusing Ability”)Visual Processing SkillsFunctional Training
Accommodation Focusing ability of the eye Changes in lens shape, pupil size, and position of eyes
Accommodative Dysfunction Blurred vision Eye strain Headaches Difficulty reading and concentrating Avoidance of near work Difficulty taking notes/copying information from board41.9 - 51% presented with accommodative dysfunction (Gallaway etal., 2016; Master et al. 2016)
Accommodation Near/far transitions in gaze Subjective report Blurred vision more at nearthan distance Age Referral to optometry
Accommodation - TreatmentOptometry dx: accommodation insufficiency with recommendation for completion of see-throughaccommodative rock with bullseye target
Treatment DomainsSymptom Management / ModificationsOcular Motor SkillsBinocular VisionAccommodation (“Focusing Ability”)Visual Processing SkillsFunctional Training
Visual Processing Dysfunction Lack of coordination and balance Clumsiness; falls and bumps into things Knocks over objects or misses objects when reaching for them Inaccuracy with keys and buttons Right vs. left confusion (directionality) Poor attention to detail Difficulty copying /sloppy handwriting or drawing Poor recall of visual material Difficulty with activities with high demand on visual processing(driving, reading, writing, sports, mobility)
Visual Processingand Perceptual Skills Visual Spatial Skills Peripheral awareness Bilateral integration Directionality Visual Analysis Figure ground Visual discrimination Visual closure Visual memory/visualization Form constancy Visual-Motor Integration Visual processing speed/reaction time(baseball.isport.com)
Visual Perceptual Dysfunctionin TBI Visual and visual-perceptual impairments associated withtraumatic brain injury (TBI) are prevalent, with estimates as highas 90% (Jacobsen and Marcus, 2011) 31% of people with severe TBI were found to have visualperceptual impairments one year post injury (Kersel et al, 2001) Central and peripheral vision reaction times are prolonged inpatients with post concussion visual dysfunction with peripheralvisual reaction time being disproportionately prolonged (Clark etal, 2017) Reaction times were found to be longer in mild TBI accompaniedby an increased variability of response (Piponnier et al, 2016) TBI patients exhibited poorer performance on visuo-spatial taskssuch as maze learning. (Coetzer and Stein, 2001) TBI patients were found to have impairments in verbal and visuospatial working memory (Kumar et al, 2013)
Visual Processing - Assessment Lafayette Grooved Pegboard Developmental Test of VisualPerception – Adult form (DTVP- A) Trail Making Test Part A & B Functional observations Patient report
Visual Processing - AssessmentLafayette GroovedPegboard
Developmental Test of Visual Perception(DTVP-A)
Copying Subtest (DTVP- A)InitialRe-test
Brain Injury Vision Symptom Survey(BIVSS)Predictive score of visualdysfunction 31Laukkanen, H., Scheiman, M., & Hayes, R(2016). Brain Injury and Symptom Survey(BIVSS) Questionaire. Optometry and VisionScience, 93, 00-00.
Trail Making Test Part A & B
Visual Processing - TreatmentDynavision D2TM Visual processing speedReaction timePeripheral awarenessVisual motor integrationSaccadic eye movement
Visual Processing - TreatmentVideo
Visual Processing -TreatmentVideo
Visual Processing - Treatment
Visual Processing - TreatmentVideos
Visual Processing - TreatmentVideos
Treatment DomainsSymptom Management / ModificationsOcular Motor SkillsBinocular VisionAccommodation (“Focusing Ability”)Visual Processing SkillsFunctional Training
Functional TrainingAssessmentApproach Prior level of function Current functionalperformance Canadian OccupationalPerformance Measure Reintegration Graded return Endurance building Desensitization Adaptive strategies/taskanalysis
onReadingBaseline: 10Baseline:2 (5 min)Baseline: 2Discharge: 10Discharge: 8(45-60 min)Discharge:8Baseline: 10Baseline:2 (30 min)Baseline: 2Discharge:10Discharge: 8 (60 minincrements)Discharge:8Grocery shopping/Outwith friends incommunityBaseline: 10Baseline:2Baseline: 2Discharge:10Discharge: 7Discharge: 7DrivingBaseline: 10Baseline:1Baseline: 1Discharge: 10Discharge: 6Discharge: 6Computer useBaseline:Discharge:Average Performance: 1.75Average Satisfaction: 1.75Average Performance: 7.25Average Satisfaction: 7.25
Functional TrainingPicture
Functional TrainingVideo
Functional TrainingVideo
Functional TrainingPicture
Functional Training
Functional TrainingPicture
THANK YOU! Questions ?
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References Scheiman, M., Mitchell, L., Cotter, S., Cooper, J., Kulp, M., Rouse, M., Borstin, E., London, R., & Wensveen, J. (2005).A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmology, 123, 14-24. Storey, E. P., Master, S. R., Lockyer, J. E., Podolak, O. E., Grady, M. F., & Master, C. L. (2017). Near point ofconvergence after concussion in children. Optometry and Vision Science, 94(1), 96-100. Sussman, E. S., Ho, A. L., Pendharkar, A. V., & Ghajar, J. (2016). Clinical evaluation of concussion: The evolving roleof oculomotor assessments. Neurosurgical Focus, 40(4), E7. Richman, J. E., Walker, A. J., & Garzia, R. P. (1983). The impact of automatic digit naming ability on a clinical test ofeye movement functioning. Journal of the American Optometric Association, 54(7), 617-622. Ripley, D.L, Politzer, T., Berryman, A., Rasavage, K., & Weintraub, A. (2010). The vision clinic: An interdisciplinarymethod for assessment and treatment of visual problems after traumatic brain injury. NeuroRehabilitation, 27, 231-235. Sterner, B., Abrahamsson, M., & Sjostrom, A. (2001). The effects of accommodative facility training on a group ofchildren with impaired relative accommodation—a comparison between dioptric treatment and sham treatment.Ophthalmic and Physiological Optics, 21(6), 470-476. Swanson, M.W., Weise, K.K., Dreer, L.E., Johnston, J., Davis, R.D., Ferguson, D., Heath Hale, M., Gould, S.J., Christy,J.B., Busettini, C., Lee, S.D., & Swanson, E. (2016). Academic difficulty and vision symptoms in children withconcussion. Optometry and Vision Science, 94, 60-67. Wells, A.J., Hoffman, J.R., Beyer, K.S., Jajtner, A.R., Gonzalez, A.M., Townsend, J.R., Mangine, G.T., Robinson, E.H.,McCormack, W.P., Fragala, M.S., & Stout, J. R. (2013). Reliability of the Dynavision D2 for assessing reaction timeperformance. Journal of Sports Science and Medicine, 13, 145-150. Wilkins, A.J. (2005). Visual Stress in Neurological Disease. Advances in Clinical Neuroscience Rehab, 4, 22-3. Womack, K. B., Paliotta, C., Strain, J. F., Ho, J. S., Skolnick, Y., Lytton, W. W., Turtzo, C.L., McColl, R., Diaz-Arrastia,R.D., & Bergold, P. J. (2017). Measurement of peripheral vision reaction time identifies white matter disruption inpatients with mild traumatic brain injury. Journal of Neurotrauma, 34(8), 1539-1545. Ventura, R.E., Balcer, L.J., Galetta, S.L. (2015). The concussion toolbox: The role of vision in the assessment ofconcussion. Seminars in Neurology, 35(5), 599-606. Zelinsky, D.G. (2010). Brain injury rehabilitation: cortical and subcortical interfacing via retinal pathways. AmericanAcademy of Physical Medicine and Rehabilitation, 2, 852-857.
Cover / Uncover Test Maddox Rod / Phoria Cards . Maddox Rod. Binocular Vision - Assessment Convergence Normal Break at 4 inches (10cm) Abnormal Convergence Binocular Vision - Assessment Video. Children ( age 21) total score 16 or higher is suggestive of convergence
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