1. Dr. Jennifer J. KungleThe Center for Vision DevelopmentAnnapolis, Maryland

2. Outline1. What is Neuro-Optometric Rehabilitation?2. Interdisciplinary Approach to Treatment3. Visual Field Loss Vs. Visual Spatial Inattention4. Treatment with lenses/prisms/patching5. The Vestibular Connection6. Visual Perceptual Deficits7. Visual Evoked Potentials 3. What is Neuro-OptometricRehabilitation?A service which provides, coordinates and managesall of the visual needs of patients withneurological insultNeuro in NOR External Insults Closed or penetrating trauma Internal Insults Stroke (CVA), brain surgery 4. Neuro-Optometric RehabilitationOptometric in NOR Eye Health Visual Field Refractive Needs Prism Occlusion Low Vision Visual Rehabilitative Therapy 5. Neuro-Optometric RehabilitationRehabilitation in NOR Multidiscipline Team Occupational Therapist, Physical Therapist, VestibularTherapist, Speech Therapist, Cranio-Sacral Therapist,Physiatrist, Psychologist, Case Worker, Neurologist,Cardiologist, Internist, Audiologist, Ophthalmologist,Attorneys, Educators, Insurance Case Worker, MobilitySpecialist Communication with the entire team ADVOCACY to help the patient rehabilitate 6. Right/Left Brain GeneralizationsRight Brain Damage1. Left Hemiplegia, hemianopia2. Neglect of left side of self and/or space3. Lack of recognizing objects, people, colors(Agnosia's)4. Spatial inaccuracies in judgments of speed ofmotion5. Lost in Space 7. Left Brain Damage1. Right hemiplegia, hemianopia2. Neglect of right side of space (rare)3. Language difficulties, Aphasias 8. Neuro-Optometric RehabilitationTimeline of Care:1. Acute Assessment in Hospital ER2. Assessment in Rehab Facility Begin in-patient therapies May receive a vision evaluation/initial treatment3. Outpatient care or homecare 9. Visual Field Deficits Extremely common following acquired brain injury Varies from small scotomas to a completehomonymous hemifield Causes changes in perception of 3/D space Disrupts binocular vision; may cause double vision 15% of patients with homonymous hemianopia experiencediplopia Shifts center of gravity causing balance and mobilityissues Right field loss near the fovea significantly impactsreading as previewing next word in periphery ishindered 10. Visual Field Deficits Visual field deficits occur in approximately 40%of patients with a TBI; 67% of patients with acerebral vascular accident (CVA) Most deficits with CVAs are homonymous(30%); scattered (13%); nonhomonymous(13%); or restricted visual field (8%) With TBI population, scattered deficits (22%),homonymous (9%), restricted field (6%) andnonhomonymous (1%) 11. Perimetric testing The normal visual field extends 60 degreesnasally and 90 degrees temporally Standard visual field testing is performed on a30 or 24 degree field; however for these typesof patients a 60 degree field test is ideal tofully assess their visual function Perimetric testing is not always possible due tophysical, cognitive, behavioral or attentive states 12. HumphreysVisual FieldAnalyzer 13. FDTVisual FieldAnalyzer 14. Tangent Screen 15. Treatment Homonymous hemianopia will show some sign ofspontaneous resolution in 50-60% of patientswithin the first 6 months Little has been shown to improve beyond thistime frame spontaneously; however improvementscan be made with specific rehabilitative techniques 16. Treatment Quadrant field lossSuperior Field Loss Patients need warning about overhead lightingand cabinets, and should be reminded to scannew environments they enterInferior Field Loss Interfere with reading and mobility and shouldbe treated similar to a patient with ahemianopic deficit 17. TreatmentsDouble Vision Treatment to restore binocular vision can beemployed with optometric vision therapy Assessment should be made as to whether theloss of binocularity is helpful in overcoming avisual field deficit by expanding the visual field.If so, cling patches or occlusion foils can beutilized to address the double vision in primarygaze. Binasal Occluders Prism 18. TreatmentsPerceptual Speed critical for safety Tachistoscope training (Flash games) Computer programsScanning Practice large saccades into the blind field,followed by smooth pursuit in oppositedirection Limit head movement (limit vestibularinput) Must also be practiced while moving 19. TreatmentsBorderzone Stimulation Most field recovery happens at the blindedge of the sighted field in homonymoushemianopiaPeripheral Prism Application Gottleib prism mounted on peripheral edgeof lens Shifts blind field towards midline once youlook into the prism 20. Gottleib Prism 21. TreatmentsPrism for Balance Yoked prism can be used to realign a patientscenter of gravity and improve overall balance 22. Visual-Spatial Inattention Cognitive deficit that refers to a relative lack ofawareness to objects, people or visual stimulipresented in the visual space contralateral tothe location of the cerebral lesion Also referred to as visual-spatial neglect,unilateral spatial inattention (USI), visual hemi-inattentionor visual imperception Between 65-80% of patients with a stroke havebeen reported to experience visual-spatial neglect 23. Visual-Spatial Inattention Frequently associated with hemianopia,hemiparesis and other perceptual andsensorimotor deficits Typically left visual-spatial neglect occursfollowing a right hemispheric injury; this form ismore common and longer lasting than right sidevisual-spatial neglect It will vary from person to person in severity 24. Visual-Spatial Inattention Patients with left visual-spatial neglect will veerto the left when walking or bump their leftshoulder on door frames They will frequently lose their spatial orientationand become confused even in familiarenvironments. While eating they will leave food on the left sideof their plates; they will forget to comb orshave the left side of their face; may bestartled by presence of their left arm 25. Visual-Spatial InattentionThe Parietal Lobe is the most common locationfor the lesion causing visual-spatial neglect.Other studies have found lesions in the frontallobe, parietofrontal white matter tracks,subcortical regions (basal ganglia, pulvinar) andthe dopaminergic pathways.The patient is unaware of the spatial loss anddenies that a problem exists 26. Testing forVisual-Spatial Inattention1. Extinction Test via Confrontational Fields2. Line Bisection Task3. Letter Cancellation4. Hart Chart5. Picture Scanning6. Picture Drawing 27. Testing forVisual-Spatial Inattention 28. Hart Chart 29. Draw a clock Test 30. Interventions forVisual-Spatial InattentionCompensatory Draw a red highlighted line down the verticalmargin of each page; can use a red velcro strip,ruler or reading guide Turn the page 90 degrees to avoid reading acrossthe body midline Trace underneath sentences with a pen to keeptrack of what has been read Brightly colored T-square to help with trackingand returning to the left margin 31. Interventions forVisual-Spatial InattentionRehabilitative Activities Tracking exercises, visual search techniques Margolis eye throwing technique Involves proprioception and kinesthetic cueing to ensurecomplete scanning of the environment Body Image Awareness Silhouette Body Lifts Prism Adaptation 2 week trial minimum Alters perception of space 32. Post Traumatic Vision Syndrome1. Convergence Insufficiency2. Exotropia/High Exophoria3. Accommodative Deficiencies4. Photophobia5. Low Blink Rate6. Visual Spatial Distortions7. Oculomotor Deficits (saccades, pursuits)8. Difficulties with attention and concentration 33. The physical lines of print appear to create anirritating set of mirages in up to 50% of allreaders whose brains are hyper-reactive tomost sensory inputs. These illusions take a number of forms, butmost frequently make the print seem tomove on the page with a flowing, rippled lookor a swirling of the text in the periphery ofones vision. 34. Lens Treatments1. Avoid multifocals *****2. Always consider two pairs of glasses3. May also require additional computerRx4. Tints, polarization, anti-glare coatings5. May require additional wrap aroundsunglasses 35. Prism Treatments1. Compensatory Prisms Fresnel Press-On Prisms (temporary) 36. Fresnel Prisms 37. Prism Treatments1. Compensatory Prism - monocular Base Out for Esotropes Base In for Exotropes Vertical Prism for Hyper/Hypotropias Oblique axis2. Therapeutic Prisms Yoked-Prism Shift spatial world to improve midline shifts, balanceand mobility, enhance stereopsis, eliminate visual-spatialinattention 38. Occlusion TreatmentsElastic Patches avoid solid pirate patch, opt for atranslucent/frosted clear patch whenever possible great for patients who dont wear glasses still allows for peripheralawareness 39. Occlusion Treatments Cling Patches (Bangerter Occlusion Foils)can vary from opaque (light perception) tovarying degrees of translucency Provide varying acuities, i.e. 20/50,20/200, light perception 40. Occlusion Treatments Partial or spot patches can be used as immediatetreatment for double vision. Partial patches will allow the patient to maintainperipheral awareness and facilitates their overallcoordination and balance. Occlusion Therapy without an assessment is NOTrecommended. 41. Superior Occlusion 42. Inferior Occlusion 43. Spot Occlusion 44. StreffWedge 45. Binasal Occluders Encourages divergence Eliminates cross fixation with esotropes 46. Bitemporal Occlusion Promotes convergence Helpful for some exotropes or high exophores 47. Where to find these products?Bernell Vision CorporationBernell.com Wholesale prices to vision specialistsOptometric Education FoundationOepf.org 48. Visual-Vestibular ProcessingThere is an intimate relationship between vision,vestibular and motor processing Stand on one foot: balance is achieved due toinput from vision, vestibular and proprioception Stand on one foot with eyes closed: you start tolose your balance because visual information is lostto provide motion stabilization 49. Visual-Vestibular Processing Dynamic Visual Acuity Use Snellen Chart; lateral head movements 2cycles per second 2 line drop in acuity Abnormal VestibularFunction Do lenses improve or reduce acuity? Watch for progressive lenses/bifocals 50. Vestibular-Ocular Reflex Reflexive eye movement in the opposite directionto head movement in order to stabilize retinalimage and prevent BLUR One of the fastest reflexes in the body Stimulation of semicircular canals send impulsealong CN VIII; contralateral CN VI nuclei; lateralrectus/opposite medial rectus (CN III) eyemuscles 51. VOR Gain Change in the eye angle divided by change in headangle during head movement Ideally VOR Gain = 1 It will vary if bifocals/progressive lenses are worn Low plus lenses will magnify and increase VORgain, thus decreasing dizziness; can eliminate needfor sunglasses Eye tracking exercises will increase VOR Gain 52. Dizziness Optometric Management Need to stress peripheral awareness and switchfrom central (focal) to peripheral (ambient)quickly to minimize dizziness Assess blink patterns, to aid refixation which willdecrease dizziness Encourage multiple fixations duringwalking/turning, visual anchors 53. Visual Information Processing Active process of locating, extracting andinterpreting visual information from the environment These deficits can be academically, socially andvocationally disablingSymptoms: Difficulties with attention and concentration Memory deficiencies Decreased processing speed Poor spatial orientation 54. Visual MemoryThe true art of memory is attention.Samuel Johnson Memory deficits are one of the most persistenteffects of TBI. Reported to occur in approximately 70-80% ofvictims. Impact day to day functioning. Prevent patients from returning to work. Prohibit independent living. 55. Pooh looked at his two paws. He knew that oneof them was the right and he knew that whenyou had decided which one of them was the rightthen the other was the left; but he could neverremember where to begin.A.A. Milne 56. Visual Spatial Deficits Figure-ground discrimination Visual closure Form perception Right/left discrimination Visualization Visual thinking Visual logic/reasoning 57. Copyright Diopsys, Inc. 2012. All Rights Reserved. Patent Pending.How MUCHHow FAST 58. Clinical Indications for VEP Visual Disturbances Amblyopia Subjective Disturbances Double Vision Binocular Vision Disorder Visual Field Defect Color Vision Deficiencies Night Blindness Disorders of the OpticNerve & Visual Pathway Papilledema Optic Atrophy Glaucomatous OpticAtrophy Drusen of the OpticDisc Optic Neuritis Injury to Eye or Brain TBI Concussion 59. Additional Information www.nora.ccNeuro-Optometric Rehabilitation Association www.covd.orgCollege of Optometrists in Vision Development www.marylandvisiontherapy.com drkungle@marylandvisiontherapy.com 60. Thank you!