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Visual Assessment in Acute Care
Why we contacted Dr. Cohen
Vision Toolkit
Possible interventions
Case study (if enough time)
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Why did we contact Dr. Cohen?
We frequently noticed visual impairments.
What do we assess? How? How do we describe what we
see? How do we intervene?
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What did we learn?
• How to better assess vision in acute setting
• Assessment priorities for Neuro and Trauma populations
• Developed Vision Toolkit
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Vision Toolkit
Quick and accessible reference
Describes how to assess and how to intervene
(Appendix A)
• Basic assessment- subjective report, visual acuity,
extraocular muscles (EOM), visual fields, and
inattention
• Advanced assessment- eye alignment, fusional
vergences, saccades, and visuoperception
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Visual Acuity Interventions
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Increase contrast
Compensate with tactile or auditory cues
Teach navigational skills
Advocate for environmental consistency
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EOM Interventions
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Compensatory head movements
Increase visual attention to affected area
Adaptive equipment
Sorting tasks if difficulty with smooth pursuit
Compensatory head positioning if nystagmus
Cranial nerve glides if impaired quality of movement?
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Visual Fields Interventions
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Compensatory head movements
Increase visual attention to affected area
Dynamic overhead reach tasks
Obstacle avoidance during
mobility tasks
• Reading comprehension or
functional pen-and-paper tasks
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Inattention Interventions
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Present stimuli in affected area
Teach systematic scanning
Increase visual attention to affected area
Increase sustained attention
Recalibrate midline
Stress physical interaction with blind side environment
Cover intact half-field of lenses
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Case Study, Background
J.K. is a 53-year-old male, married, with a 12-year-old son, and
no longer able to work.
• History of pituitary mass, skull base mass with C2 spinal cord
compression, recent fall in bathroom, and cerebrospinal fluid
leak requiring placement of ventriculoperitoneal shunt
• Presenting with recent blindness, minimal bimanual sensation,
impaired activity tolerance, dependence on wheelchair for
mobility, and frustration and anxiety related to situation
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Case Study, Interventions
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Customized dining tray
Built-up handles for utensils
Education in clock-based orientation system
Progressive positioning for activity tolerance
Emphasis on self-efficacy and problem solving
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Case Study, Outcomes
Following 3 sessions and with lots of encouragement:
• Set-up assistance to eat while sitting for at least 15
minutes
• Stand-by assistance with verbal cues for navigation to
ambulate 150 feet with front-wheeled walker
• Markedly more positive mood
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References
• Gutman, S.A. & Schonfeld, A.B. (2009). Screening adult neurologic populations:
A step-by-step instruction manual, (2nd ed.). Bethesda, MD: AOTA Press.
• Hamby, J.R. (2011). The nervous system. In H. Smith-Gabai (Ed.),
Occupational therapy in acute care (pp. 183-298). Bethesda, MD: AOTA Press.
• Luauté, J., Halligane, P., Rodea, G., Rossettia,Y., & Boisson, D. (2006).
Visuo-spatial neglect: A systematic review of current interventions and their
effectiveness. Neuroscience and Biobehavioral Reviews, 961-982.
• Zoltan, B. (2007). Vision, perception, and cognition (4th ed.). Thorofare,
NJ: SLACK Incorporated.
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Appendix A
VISION TOOLKIT
Visual impairment screen for acute care occupational therapists
KEY POINTS
Select a small, high-contrast stimulus
Complete items with corrective lenses when available
“Near distance” for assessment often refers to a point 12 to 16 inches from bridge of nose
SUBJECTIVE REPORT
Any history of visual impairments?
Does the person use corrective lenses? If so, are they available?
Any acute changes that could be related to vision (e.g., blurriness, floaters, eye fatigue, headaches, double vision)?
BASIC ASSESSMENT
Item
Visual Acuity
How to Assess
How to Intervene
Distance Acuity:
·
·
·
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Use distance eye chart
Tape chart to windowless wall in well-lit room
Have person stand or sit at indicated distance from chart
Check right eye (OD), then left eye (OS), and finally both eyes
together (OU)
· Have person read one line at a time, from large to small font
· Continue until person cannot read a majority of letters on line
· Increase contrast (e.g., reduce visual stimuli, increase font size, improve
lighting, increase figure-ground separation)
· Compensate with increased tactile or auditory stimulation (e.g. pieces of
hook-and-loop fastener for call light)
· Teach navigational skills (e.g., “clock-method”)
· Advocate for consistency of object placement in environment
· Educate on use of a guide when necessary (may include family/caregiver)
OR
· Stand directly opposite person
· Determine greatest distance at which person can differentiate random
number of fingers presented in hand
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Appendix A
Near Acuity:
· Use 3-in-1 Near Visual Acuity test
· Follow directions as above
· Consider assessing near before far acuity if person cognitively impaired
due to decreased attention demands
Extra Ocular Range
of Motion
· Present stimulus at near distance
· Complete figure-of-X and figure-of-H patterns
· Observe for smooth pursuits, conjugate eye movements, nystagmus,
and compensatory head movements
· Contact team immediately if eye inferolaterally deviated (may be sign
of aneurysm), medially deviated (may be sign of increased ICP), or
laterally deviated (may be sign of vasculopathic tumor)
· Teach compensatory head movements to affected area
· Promote increased visual attention to affected area
· Teach use of compensatory strategies or adaptive equipment for reading
(e.g., “window” templates to isolate text or format checks)
· Work on sorting items (e.g., clothes, coins, utensils), item retrieval
following a list, or information search (e.g., from newspaper, brochure,
website) if difficulties with smooth pursuit movement
· Use semi-opaque material (e.g., clear tape) to cover affected hemifield of
lense and help prevent double vision
· Teach compensatory head positioning in gaze position of least eye
movement (null point) if nystagmus
· Consider cranial nerve glides if full ROM but impaired quality of
movement
Visual Fields
· Assess one eye at a time
· Have person focus on object at eye level in middle distance
· For left and right quadrants, stand behind person and bring stimulus in
near distance arc from just posterior to shoulder to sagittal midline;
repeat for opposite visual field
· For superior quadrants, stand behind person and bring stimulus in near
distance arc from directly overhead to eye level
· For inferior quadrants, stand off-center to person and bring stimulus in
near distance arc from waist to eye level
· Person reports when stimuli first detected
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·
·
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Teach compensatory head movements to affected area
Promote increased visual attention to affected area
Dynamic overhead reach tasks if superior quadrants affected
Obstacle avoidance during mobility tasks if inferior quadrants affected
Use reading comprehension or pen-and-paper tasks to improve overall
functional scanning if inferior quadrants affected
OR
· Assess one eye at a time
· Sit directly opposite person and have person fixate on object straight
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Appendix A
ahead (e.g., your nose)
· Hold up one to three fingers in single quadrant at near distance; repeat
in all quadrants
· Test end range of periphery; use your own vision as a guide by closing
complimentary eye (e.g., close right eye if assessing person’s left eye)
· Person reports number of fingers presented
Inattention
(Neglect)
Generalized Inattention:
· Observe person throughout assessment to determine level of attention
to various visual stimuli
· Use objective measure of inattention
Midline Shift:
· Stand off-center to person and have person focus on object at eye level
in middle distance
· Bring stimulus in near distance arc from just posterior to one shoulder,
across midline, and towards opposite shoulder
· Bring stimulus in near distance arc from waist, across eye level, and
towards overhead
· Person reports when object perceived to be at midline
· Note direction and distance of any deviation
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·
·
·
·
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Present stimuli to affected area to promote visual scanning
Teach systematic scanning that begins in affected area
Promote increased visual attention to affected area
Increase sustained attention
Recalibrate midline (e.g., rotate trunk-on-head 15 degrees)
Stress physical interaction with environment in affected area (e.g.,
reaching out to touch items)
· Use semi-opaque material to cover intact half-field of lenses (e.g., right
half of both lenses) to facilitate attention shifts away from intact side and
towards impaired side
Visual Extinction:
· Sit directly opposite person and have person fixate on object straight
ahead (e.g., your nose)
· Hold 2 objects or fingers 8 inches apart in opposite visual fields at near
distance
· Move either object or finger a few times
· Person reports which finger moved
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Appendix A
ADVANCED ASSESSMENT
Item
Eye Alignment
How to Assess
How to Intervene
Tropias (unilateral cover/uncover test):
· Suspect if person reports double vision
· Sit directly opposite person and have person fixate on object straight
ahead (e.g., your nose)
· Observe for eye misalignment at rest
· Occlude one eye for 1-2 seconds while observing for movement of
non-occluded eye; repeat 3 times before assessing opposite eye
· Movement of non-occluded eye suggests tropia in aspect OPPOSITE
direction of deviation
· Movement inward suggests exotropia, outward suggests esotropia,
downward suggests hypertropia, and upward suggests hypotropia
· Fusion training with Lifesaver cards or 3-Coins puzzle
· Teach use of compensatory strategies or adaptive equipment for reading
· Use semi-opaque material to cover central vision aspect of single lense to
preserve input to ambient system or eye patch to occlude whichever eye
person prefers (i.e., no need to alternate eyes in acute setting) to address
double vision
Phorias (alternating uncover/cover test):
· Sit directly opposite person and have person fixate on object straight
ahead (e.g., your nose)
· Occlude one eye for 1-2 seconds, then uncover and rapidly occlude
opposite eye for 1-2 seconds taking care to prevent binocular fixation,
observe for movement of occluded eye as eye is uncovered; repeat 3
times
· Movement of occluded eye as eye uncovered suggests phoria in aspect
OPPOSITE direction of deviation
· Movement prefixes as above, however suffix is –phoria
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Appendix A
Fusional Vergences
· Hold stimulus roughly 30 inches away from bridge of nose at eye level
and ensure person can see object clearly before continuing
· Slowly bring stimulus to bridge of nose
· Observe for broken fusion (e.g., unilateral eye deviation), though
person may not notice anything unusual due to cortical suppression
· Person reports “break point” when double vision arises during
convergence
· Slowly bring stimulus away from bridge of nose
· Person reports “recovery point” when fusion resumes during
divergence
· Break point greater than 4 inches from bridge of nose suggests
impairment
· Brock string
Saccades
· Suspect possible impairment if lesion to cerebellum, parietal lobe, or
frontal lobe
· Hold 2 objects or fingers 8 inches apart in opposite visual fields at near
distance
· Instruct person to look at each object or finger on command without
moving head
· Observe for uncoordinated eye movements (e.g., dysmetria, delay)
and sustained attention including ability to resist urge to divert
attention away from object before given command
· If dysmetria (cerebellar lesion), work on saccade worksheets and grade so
target items are progressively closer to midline
· If reduced saccades (parietal lobe lesion), focus on making decisions to
scan environment and quickly take in visual input from all visual fields
· If hyperreflexia (frontal lobe lesion), maintain visual attention while
ignoring peripheral stimuli (e.g., have person describe in detail object in
central vision)
· Teach use of compensatory strategies or adaptive equipment for reading
· Use semi-opaque material to cover binasal aspects of lenses
Visuoperception
· Includes visuospatial awareness, visual closure, visual discrimination,
visual memory, and figure-ground
· Use Motor-Free Visual!Perception Test or another objective measure
· Numerous possible interventions, often deferred until post-acute
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Appendix A
REFERENCES
Freeman, E. (2001). Unilateral spatial neglect: New treatment approaches with potential application to occupational therapy. American Journal of Occupational Therapy, 55, 401-408.
Gutman, S.A. & Schonfeld, A.B. (2009). Screening adult neurologic populations: A step-by-step instruction manual, (2nd ed.). Bethesda, MD: AOTA Press.
Hamby, J.R. (2011). The nervous system. In H. Smith-Gabai (Ed.), Occupational therapy in acute care (pp. 183-298). Bethesda, MD: AOTA Press.
Luauté, J., Halligane, P., Rodea, G., Rossettia, Y., & Boisson, D. (2006). Visuo-spatial neglect: A systematic review of current interventions and their effectiveness. Neuroscience
and Biobehavioral Reviews, 961-982.
Rucker, J.C. & Tomsak, R.L. (2005). Binocular diplopia: A practical approach. The Neurologist, 11 (2), 98-110.
Zoltan, B. (2007). Vision, perception, and cognition (4th ed.). Thorofare, NJ: SLACK Incorporated.
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Questions?
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